Clinical Nurse Navigator Medicare Advantage Risk and Care Integration RN Remote in EST

Opportunities with ProHealth Physicians, part of the Optum family of businesses. When you work at ProHealth Physicians, your contributions directly sustain the health and well-being of our community. Discover high levels of teamwork, robust medical resources and a deep commitment to exceptional care and service. Join a leading community-based medical group and discover the meaning behind Caring. Connecting. Growing together.

The Clinical Nurse Navigator supports Optum's value based care and Medicare Advantage programs by integrating clinical expertise, member engagement, and documentation integrity. This role serves as a clinical liaison across members, providers, internal teams, and vendor partners to ensure accurate chronic condition capture, closed loop care coordination, and improved quality and risk adjustment outcomes.

The Clinical Nurse Navigator performs RN level validation of Hierarchical Condition Categories (HCCs), reduces reliance on external vendor over read services, and ensures timely follow up on conditions, orders, referrals, and preventive care gaps. Through proactive member navigation and provider collaboration, this role helps strengthen care continuity, optimize clinical documentation, and support Optum's commitment to delivering high quality, cost effective, and member centered care.

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

Primary Responsibilities:

• Clinical Documentation Integrity & Risk Adjustment
  • Perform RN level review of clinical documentation to validate chronic condition capture and appropriate HCC support
  • Identify and address missed, unsupported, or inaccurately documented diagnoses
• Closed Loop Care Coordination
  • Ensure closed loop follow up on identified condition screening and care gaps identified during AWV   
  • Collaborate with members and care teams to address barriers to care completion
• Member Navigation & Engagement
  • Support new Medicare Advantage member engagement 
  • Facilitate connection to the attributed Care Team
  • Promote continuity of care and participation in preventive and wellness programs
• PCP Attribution & Care Alignment
  • Facilitate and validate PCP attribution corrections to ensure accuracy and alignment with member care
  • Collaborate with operational partners to resolve attribution discrepancies
• Vendor Collaboration & Oversight
  • Review vendor clinical documentation for accuracy, completeness, and clinical appropriateness
  • Provide feedback and insights to support vendor quality and performance improvement
• Reporting & Performance Insights
  • Contribute to monthly reporting related to documentation integrity  and member engagement
  • Provide actionable insights to leadership and cross functional partners

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 Registered Nurse (RN) license in Connecticut (CT), New York (NY), or New Jersey (NJ) 

  • Ability to obtain and maintain active licensure in the remaining states upon hire

• 5+ years of clinical practice experience
• Reside within the Eastern Standard Time Zone
• Experience working in a provider based or physician (MD) office setting
• Proficiency with Microsoft Office applications, including Word, Outlook, Excel, and PowerPoint
• Demonstrated ability to apply clinical judgment across medical records, workflows, and care settings

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN)
• Experience supporting Medicare Advantage Risk Adjustment
• Billing and coding experience and/or medical office management experience
• Solid understanding of coding principles, including ICD 10 and documentation requirements
• Proven solid facilitation, consulting, and communication skills, with the ability to deliver complex clinical and operational information to diverse audiences

*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 $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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.