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LPN Auditor - Clinical Quality Management - Southern Arizona
UnitedHealth Group     Tucson, AZ 85702
 Posted 29 days    

At UnitedHealthcare, 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 equitable. Ready to make a difference? Join us to start **Caring. Connecting. Growing together.**

This position will be responsible for the gathering and auditing of medical records from contacted medical providers. Analyze, track, and report results. Recommend, develop, educate and implement quality improvement plans with providers and follow up as necessary.

If you reside in Southern Arizona, you’ll enjoy the flexibility to work remotely * as you take on some tough challenges. Must reside locally in the area to travel about 50% of the time.

**Primary Responsibilities:**

+ Review and audit Medicaid (AHCCCS) Electronic Visit Verification (EVV) providers and medical records regarding AHCCCS AMPM requirements around EVV

+ Review, audit and evaluate documentation of medical records

+ Review/interpret medical records/data to determine whether there is documentation reflected accurately in medical record

+ Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation

+ Prioritize providers for medical chart review according to collaboration with other Health Plans

+ Identify incomplete/inconsistent information in medical records and label missing measures/metrics/concerns

+ Review relevant tool specifications to guide chart review

+ Review/interpret/summarize medical records/data to address any quality of care questions

+ Verify necessary documentation is included in medical records

+ Maintain HIPAA requirements for sharing minimum necessary information

+ Based on review of clinical data/documentation, identify potential quality of care issues (e.g., variations from standard practice potentially resulting in adverse outcomes) and potential fraud/waste/abuse.

+ Refer issues identified to relevant parties (e.g., review committee, Case Management, Medical Directors) for further review/action

+ Discuss with provider offices to address and request corrective action plans

+ Educate provider representatives/office staff to address/improve auditing processes

+ Educate providers on proper medical record documentation for regulatory compliance

+ Educate providers offices on specifications/measures

+ Explain/convey technical specifications regarding action plans/follow up

+ Explain how provider scores are calculated/determined

+ Demonstrate knowledge of public healthcare insurance industry products(Medicaid

+ Demonstrate knowledge of Medicaid benefit products including applicable state regulations

+ Demonstrate knowledge of applicable area of specialization (e.g., community based services)

+ Demonstrate knowledge of computer functionality, navigation, and software applications (e.g., Windows, Microsoft Office applications, phone applications, fax server)

+ Demonstrate knowledge of specific software applications associated with the job function (e.g., navigation of relevant computer applications or systems, intranet databases, records management or claims database

+ Prepare for and participate in meetings with State agencies, providers, and stakeholders as well as internal meetings

+ Assist with other quality management audits, corrective action plans as needed

+ This position will have on site provider location visits throughout Arizona

+ This position is a work from home position with 50% in state travel

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:**

+ High School Diploma/GED (or higher)

+ Active and unrestricted LPN license in the state of Arizona

+ 3+ years of experience in the Medicaid health field including provider interactions

+ 2+ years of experience reviewing medical record charts/documentation and writing regulatory reports

+ Intermediate level of proficiency with software applications that include, but are not limited to, Microsoft Word, Excel and Teams

+ Reliable transportation for field visits

+ Ability to travel 50% for the position throughout Arizona when business requires

+ Reside in Arizona

**Preferred Qualifications:**

+ Background in Managed Care

+ Prior field-based work experience

+ Knowledge of EVV (Electronic Visit Verification) and HCBS (Home and Community Based Services)

+ Experience creating quality improvement plans/corrective actions plans

+ Solid Organizational Skills

+ Experience helping providers come into compliance with health plan standards

+ Knowledge of Medicaid benefit products including applicable state regulations

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

_At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission._

_Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law._

_UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

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Job Details

Employment Type

Full Time

Number of openings


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