Secondary Review Nurse - Remote in Kansas

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As a Secondary Review Nurse, you will be conducting a review of long-term support services (LTSS) for the United Healthcare Community Plan of Kansas population. This nurse will work with the service coordination teams to ensure that the LTSS services align with the state guidelines along with the policies and procedures of the health plan. Additionally, this nurse will track various reporting elements for analysis and trending along with serving as a resource to others. The Secondary Review team consists of nurses and technicians within the plan. Hours are Monday – Friday 8am – 5pm. If you are located within the state of Kansas, you will have the flexibility to work remotely* as you take on some tough challenges.

Review technical metrics/specifications/ measures Evaluate documentation of Functional Assessment, compare to adherence to form instructions. Review and compare to prior assessment for changes. Provide recommendations to SC completing assessment if areas of opportunity exist Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC) Review relevant HEDIS specifications to guide chart review Review/ interpret/ summarize medical records/data to address quality of care questions Review provider responses to reports/findings and correlate with medical records 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 Solve moderately complex problems and/or conduct moderately complex analyses Work with minimal guidance; seeks guidance on only the most complex tasks. Translate concepts into practice Provide explanations and information to others on difficult issues Coach, provides feedback, and guide others while acting as a resource for others with less experience