As a Clinical Grievances Nurse, you will be responsible for reviewing incoming retrospective cases to determine if the appropriate care was given along with current cases to ensure the members immediate needs are being addressed. In providing consumer - oriented health benefit plans to millions of people; our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.
If you are able to work PST hours, you will have the flexibility to work remotely* as you take on some tough challenges. The working hours for this role are Monday - Friday, 8 am - 5pm PST.
Primary Responsibilities
- Perform clinical assessment of healthcare services provided to our members for appropriateness
- Understand relevant state and federal grievance and peer review requirements and accreditation standards applicable for processes supported
- Receives cases from the QIS non- clinical team and reviews them against required clinical information, assessing for appropriateness and consulting with a Medical Director
- Document relevant chronology of case review and provide rationale for severity level, descriptor codes, and any applicable Improvement Action Plan (IAP) implemented
- Facilitate telephonic discussion with health care providers and/or members to obtain additional clinical information
- Provide timely, quality service to members and providers while upholding UnitedHealthcare culture values
- Act as a resource for others with less experience
- Work independently and collaborating with Medical Directors and non-clinical partners
- Function as a member of a self-directed team to meet specific individual and team performance metrics
- Manage and maintain quality and productivity metrics
Required Qualifications
- Current, unrestricted RN license in the state of residency
- 3+ years of total RN experience including recent clinical experience in an inpatient / acute setting or similar setting
- Demonstrated proficiency in computer skills - Windows, Instant Messaging, Clinical Platforms, Microsoft Suite including Word, Excel, and Outlook
- Demonstrated clinical documentation skills and critical thinking skills
- Designated workspace and access to install secure high speed internet via cable / DSL in home
- Reside in and work 8 am-5 pm Pacific Standard time zone
- Must live in the state of CA
Preferred Qualifications
- Bachelor's in Nursing or higher
- Experience with Managed Care Clinical Quality Programs
- Case management experience
- Clinical appeals and grievances experience
- Audit / chart review experience
- Experience in a telecommuting role
- Demonstrated ability to effectively utilize UHG applications, including but not limited to authorization applications, auto correspondence, and member & provider demographic systems
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
The hourly pay for this role will range from $29 - $52 per hour based on full-time employment.