Senior Clinical Quality Nurse RN, Quality Operations Call Center – Remote

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Clinical Performance Quality (CPQ) Clinical Programs Operations team supports Optum’s Care Delivery Organizations by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close Medicare STARS/HEDIS gaps in care, including medication adherence, care for older adults, medication reconciliation post discharge, A1c, Blood pressure and statin therapy in patient with diabetes and cardiovascular disease. Our interdisciplinary service delivery team is comprised of Pharmacists, Registered Nurses, Pharmacy Technicians, and Care Coordinators.  

The Registered Nurse will report into the Director of Clinical Programs. The Registered Nurse will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. In addition, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work to support the hours of operation of the business (Mon-Fri 9am-6pm Central). 

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 

Primary Responsibilities:

• Strictly adheres to department’s metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests
• Primarily to make outbound calls and will help manage the inbound call queue from patients, patient representatives, providers and other medical staff, while strictly adhering to established protocols and scripting
• Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services
• Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments 
• Educate patients on health conditions and necessity of routine screening and assisting with appointment scheduling (A1c, Controlling Blood Pressure, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.) 
• Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided 
• Review available medical records for core measures to submit for closure of HEDIS/STARS measures 
• Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs 
• Document thoroughly all calls and actions taken within core systems. 
• Performs all other related duties as assigned 

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 Registered Nurse eNLC  Compact licensure in state of residency  
• Currently have or be able to obtain additional RN licensure in one or more of the following states: Rhode Island, Massachusetts, Pennsylvania, Michigan, Illinois, California, Connecticut, Nevada, New York, Oregon
• 5+ years of RN experience, including experience in a managed care setting 
• 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role
• 2+ years of Call Center or Telephonic Outreach experience
• 2+ years of experience with data analysis and/or quality chart reviews, Must be able to review paper and electronic medical records and charts 
• Experience with and extensive knowledge of the Medicare HEDIS/Stars measures 
• Experience managing multiple complex, concurrent projects 
• Experienced using Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets with intermediate or better Excel skills

Preferred Qualifications:

• Undergraduate degree, post graduate degree 
• Billing and CPT coding experience 
• Clinical data abstraction experience 
• Bilingual with preference given to Spanish and Vietnamese 

Competencies:

• Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels 
• Excellent written and verbal communication and relationship building skills 
• Solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action 
• Excellent customer service skills and communication skills 

Physical & Mental Requirements:  

• Ability to lift up to 10 pounds 
• Ability to sit for extended periods of time 
• Ability to use fine motor skills to operate office equipment and/or machinery 
• Ability to receive and comprehend instructions verbally and/or in writing 
• Ability to use logical reasoning for simple and complex problem solving 
• Ability to use fine motor skills to operate office equipment and/or machinery 

*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 $71,200 to $127,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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.

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.