Clinical Regulatory RN - Health Services Clinical Team - Arizona Remote

apartment UnitedHealthcare location_onPhoenix, AZ, US

$58,800 - $105,000 / YEAR

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.

The Clinical Regulatory RN must be a subject matter expert (SME) for all four Arizona Health Plan lines of business and is a critical supporting team member reporting to the Director of Health Services, who reports to the VP of Health Services. This role is responsible for ensuring operational excellence and departmental adherence to all health service regulatory demands across multiple complex domains and teams (i.e., health plan; Enterprise Clinical Services; Optum), both in and outside of the health plan, across UHG.

Critical responsibilities include, but are not limited to, overseeing the full range of regulatory reporting and monitoring demands tied to contractual health service activities. These are outlined in the AHCCCS Complete Care (ACC), Developmental Disabilities (DD) and Long-term Care (LTC) Elderly Physically Disabled (EPD) contracts, as well as in the AHCCCS (and AdSS) Medical Policy Manual, Chapter 1000. These encompass the Health Services regulatory adherence demands tied directly to ongoing AHCCCS/DDD policy public comments which must be vetted, then submitted, tracking the subsequent policy changes, followed by the necessary internal health plan policy redevelopment and revisions with key stakeholders. This team member is responsible for maintaining all departmental non-policy, standard operating procedures, as supported by AMPM/AdSS Policy 1010 and contracts per line of business.

The team member is a key contributor to all the annual health service program deliverables and documents, including state-required formatting or templating updates, and tracking revisions across contributing departments. Also critical, they must coordinate the annual workplan program evaluations and data sources for the following plans: Health Services; Maternal Child Health; Dental; EPSDT; Health Equity.

Success in this role requires general clinical knowledge and an understanding of Medicaid and Medicare programs, particularly the AHCCCS and DDD systems of care, as well as Medicare Advantage programs for Dual Special Needs. This position acts as a key contributor to the Health Services Team holistically, to the extended Health Plan and to our UHG Shared Services partners. As such, this role is a critical resource during preparation and organization of documentation for regulatory audits and operational reviews (i.e., HSAG; DDD). The scope of work is dynamic, reflecting the evolving compliance landscape throughout the year, and other duties will be assigned as appropriate.

If you are located in Arizona, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities

Monitor and ensure Health Services team accurately demonstrates completion of the Contract List of Deliverables Attestation requirements, checking and validating timeframes and accuracy of information of the contracts and regulatory policies
Accountability for Regulatory Reports/Contract Deliverables, including but not limited to complete Quarterly NOA Self-Audits submission to the regulators
Serve as the central collaborative point of contact for Health Services medical regulatory policy/procedure, workflows and contract revisions
Lead monthly meetings with the Health Services Team at the direction of the HSD to monitor regulatory reporting and submissions
Verifies and monitors medical management policies and procedures against State regulatory and contract requirements as updates are received from regulators
Assist in drafting, formatting, and completion of checklist for the health plan Medical Management Annual Plan
Communicate changes of regulatory requirements or covered benefits, ensuring operational processes are implemented with external business partners impacted
Monitor and track projects utilizing spreadsheets or other project management tools
Supports the HSD and VP Health Services in monitoring and evaluating the effectiveness of the Medical Management workplans quarterly, ensuring accountable parties are completing their components within the workplan in a timely manner and addressing barriers to data acquisition or system changes
Update the tracking tool to monitor the completion of the submission of deliverables for the Health Service Team
Coordinates and drives accountability with internal team meetings and manages COPA related deliverables related to Contract, Policy, and Regulatory changes to ensure the Health Services Team has completed, implemented, and operationalized changes/edits
Ensure project timeframe compliance for Medical Management related deliverables is met by shared service teams (i.e., OBH, eviCore, DBP, Optum Rx)

Additional Responsibilities

Lead/Organize meetings to improve operation processes, projects, and Annual Plans
Identify barriers completing projects, notifying leadership and making appropriate recommendations to remove barriers
Lead functional or segment teams to complete complex projects
Provide explanations and information to others on operational process changes
Participate in the identification of best practices within Medical Management
Resolve AHCCCS/DES Ad Hoc audit request and risk management concerns in a timely manner
Provide excellent customer service by identifying and exceeding state Regulatory expectations
Timely delivery of contract deliverables
Preemptively established project workflows and team meetings to ensure completion

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 Arizona (or compact state)
3+ years of clinical or managed care experience with vulnerable/Medicaid, Special Needs, and or Medicare populations
Working knowledge and use of Microsoft software, such as MS Word and Excel and be experienced in complex project management and affiliated tracking tools and resources, including Visio and or Excel to ensure timely completion of regulatory and contract deliverables for medical management
Demonstrate problem solving skills and the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
Demonstrate clear communication and writing skills, critically review, analyze, and summarize written materials with the ability to conduct presentations when required.

Preferred Qualifications

Project Management skills
Community and/or Public Health experience
AHCCCS and or DDD knowledge and experience
UHG experience (i.e. UHC; ECS; Optum)
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. #UHCPJ

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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

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