Field LPN Auditor, Clinical Quality Management - Phoenix, AZ

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 Phoenix, AZ, you will enjoy the flexibility of a hybrid-remote role as you take on some tough challenges. Must reside locally to Phoenix, AZ.

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

What are the reasons to consider working for UnitedHealth Group?  Put it all together – competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
• More information can be downloaded at: http://uhg.hr/uhgbenefits

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
• Reside in Arizona
• Reliable transportation for field visits
• Ability to travel 50% for the position throughout Arizona when business requires

*All Telecommuters 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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