Clinical Grievances RN - Remote in CA Job Mesa Arizona USA,Healthcare

Improve the lives of others while Caring. Connecting. Growing together.

Job Description
- Clinical Grievances RN
- Remote in CA (2381848)

Clinical Grievances RN
- Remote in CA - 2381848

At United Healthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together

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 United Healthcare 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

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

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
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 United Health…