Alexandria, Louisiana
Edison, New Jersey
Great Falls, Montana
Nashville, Tennessee
Posted: 12-Dec-24
Location: Eden Prairie, Minnesota
Categories:
Internal Number: 145149275
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The Clinical Quality RN works under the supervision of the Manager of Clinical Quality to support quality audit activities for our operational clinicians, health plan partners, or regulatory agencies such as CMS. The clinical quality RN is a key member of the team that ensures our operational teams are meeting all standards set forth by our health plan delegation agreements and regulatory agencies such as the Centers for Medicare and Medicaid Services.
You’ll enjoy the flexibility to work remotely* from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Reviews Prior Authorization (PA), Inpatient Concurrent Review (IP) and/or Medical Claims Review (MCR) cases as assigned by quality manager
- Uses previous knowledge of PA, IP, and/or MCR to document observations about assigned cases, using a structured scorecard or process
- References credible sources, such as job aids, policies, CMS criteria, MCQ, InterQual, when documenting feedback on cases
- Efficiently navigate medical management platforms (Curo, Care Advance) to review cases
- Is comfortable reviewing cases live on a call, with large groups present
- Communicate succinctly and professionally with peers, leaders, executives, and health plan and regulatory auditors
- Uses knowledge of clinical process to proactively anticipate questions from auditors and provide the requested information
- Readily shares knowledge with teammates based on areas of expertise, fostering a collaborative and supportive team culture
- Is able to work independently and meet all assigned metrics and productivity goals
- Expands personal knowledge based to become a SME in the areas of PA, IP, and MCR
- Suggest process improvements, opportunities for efficiency and automation, and other feedback to drive innovation in how we work
- Complete special projects as assigned by the quality manager
- Maintain current knowledge of applicable clinical guidelines, regulatory requirements (for example, NCQA, CMS, MCG)
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:
- Active, unrestricted RN license in state of residence
- Knowledge of Curo and Care Advance medical management platforms
- Experience with Prior Authorization, inpatient concurrent review, or medical claims review
- Intermediate or higher proficiency with basic software applications including MS office, adobe, Smart Sheet
- Knowledge of CMS clinical guidelines, MCG, and InterQual
Preferred Qualifications:
- Experience with Prior Authorization
- Solid written and verbal communication skills, including presentation skills
- Ability to work independently in support of strict deadlines
- Ability to remain flexible and adaptable in the face of rapidly changing deadlines and deliverables
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $58,300 to $114,300 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
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.
