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 resources 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 is responsible for conducting clinical reviews to justify and dispute payer denials. The role will develop case studies, coordinate with hospital operations and payers to ensure optimal results in denial prevention. The clinical denial coordinator will oversee quality assurance for clinical denials, including development of protocol and training.

You will have the flexibility to telecommute* from anywhere within the U.S.as you take on some tough challenges.

Schedule : Monday – Friday – 8 AM – 4:30 PM in candidates time zone

Primary Responsibilities:

• Provide clinical argument, using available Medical Records, to justify and dispute payer denials, all levels of appeals included

• Develop monthly case studies, identifying payer and hospital operational opportunities

• Compile reports as requesting by the ROS client and operations, specific to payers, operations and clinical reviews

• Participate in performance meetings as requested by ROS client and operations

• Develop and conduct quality reviews of all clinical reviews, including training

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:

• Associate's Degree (or higher)

• Licensed RN in state of residence

• 5+ years of Utilization Review or Case Management nursing experience

• Advanced level of proficiency with Microsoft Office applications to include Excel, Word, and PowerPoint

• Intermediate level knowledge in evidence-based protocols - Hospital Case Management such as Milliman and/or Interqual guidelines

• Intermediate level of proficiency with analyzing data and presenting those findings to both leadership and operational teams

• Ability to travel up to 25% of the time

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, Hawaii or Washington Residents Only : The salary range for California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, or Washington residents is $58,300 to $114,300 per year. 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.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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.

#RPO #Green