This position works under the direction of the Manager of Patient Safety. The individual in this role will focus on investigating medical and surgical potential quality issues, patient safety events, and sentinel/serious reportable events and utilization issues by conducting retrospective chart and focused reviews. Participate on quality committees. Clinical Quality Management reviews medical-surgical quality of care and quality of service concerns. For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Schedule: Monday – Friday, 8:00 a.m. – 4:30 p.m. CT

Primary Responsibilities:

• Identifies and reviews medical surgical potential quality issues (PQIs), patient safety issues, sentinel events (SEs) and serious reportable events (SREs) by applying best practice standards of care and clinical experience
• Conducts timely reviews of electronic medical records to meet Optum standards
• Investigations include research, analysis, and preparation of written and verbal case summaries with recommendations for further actions as necessary
• Conducts detailed root cause analysis (RCA) for sentinel events (SEs) and serious reportable events (SREs)
• Ability to organize and maintain current investigation information about cases through documentation in quality of care and quality of service databases
• Communicate in writing to health care providers, track timelines, and perform follow-up as appropriate
• Develops peer review cases and other quality improvement activities identified by deviations from accepted standards of care and monitors corrective action plans to completion
• Assists with quality studies and focused reviews by abstracting medical records for specified criteria
• Participates on quality committees and presents cases to peer review quality management committee
• Collaborate with Medical Directors on complex care identified in PQIs / SEs / SREs as needed
• Read, interpret, and document standards/requirements and/or technical specifications (e.g. NCQA, NQF, WinQI, HAC)
• Work with stakeholders for review/approval of results
• Actively participate in meetings
• Train others on relevant policies, rules, and regulations
• Serve as a resource providing explanation and expertise
• Maintains confidentiality of all activities
• Performs other duties as assigned

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:

• RN with current, active license in current state
• 3+ years of clinical medical / surgical experience
• Proven ability to investigate, analyze, synthesize, and formulate conclusions
• Proven ability to organize quality data in appropriate reporting format

Preferred Qualifications:

• BSN
• Quality experience within a managed care company
• General knowledge of Medicare, VA, TRICARE, or other government health care programs
• Proven solid computer skills with emphasis on Microsoft Office software
• Proven excellent interpersonal, communication,, and writing skills
• Proven to be detail oriented and highly organized with effective time management skills
• Proven ability to work in a rapidly changing environment; Being adaptable and flexible
• Proven ability to work in a fast-paced, dynamic environment

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: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

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