Clinical Quality RN - Remote

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The RN Clinical Quality supports Optum's Medical Management and Population Health programs by ensuring compliance with CMS, NCQA, contractual, and regulatory standards across multiple lines of business. This role performs clinical documentation audits, monitors quality performance, supports accreditation and payer audits, and drives continuous quality improvement initiatives. The RN Clinical Quality serves as a subject matter expert, collaborates closely with internal and external partners, and contributes to maintaining high-quality, compliant clinical programs.

This role works independently under minimal supervision and plays a critical role in supporting quality excellence across the Mid-America region

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

Primary Responsibilities:

• Conduct routine and ad hoc audits of clinical program documentation to ensure accuracy, completeness, and compliance with CMS, NCQA, and health plan requirements
• Perform audits of internal teams and contracted partners, including pre delegation, annual, and payer-requested reviews
• Utilize standardized audit tools to review documentation across Population Health Management (PHM), case management, utilization management, and other medical management programs
• Review and audit PHM team documentation across multiple lines of business and programs
• Audit and reconcile monthly reports, including multi market universe and ORST reporting
• Analyze audit findings, interpret trends, and translate results into actionable quality improvement initiatives
• Initiate, manage, and track remediation and corrective action plans, including root cause analysis and follow up to ensure timely closure
• Serve as a Clinical Quality subject matter expert for CMS and NCQA standards related to Population and Case Management
• Prepare audit materials and participate in payer, regulatory, and accreditation audits, including case file presentation and audit walkthroughs
• Guide and influence audit processes by ensuring accurate, complete, and timely submission of required materials
• Communicate audit results, trends, and opportunities for improvement to leadership, managers, and operational teams
• Partner with training, leadership, and operational teams to identify education needs and recommend process improvements
• Support Medical Management quality initiatives, including Medical Director and departmental projects as assigned
• Maintain and update policies, procedures, and quality documentation as required
• Assist with report preparation and tracking of departmental quality activities

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 a Compact state
• 2+ years of managed care experience, including at least 1 years of case management experience
• Experience in medical management and/or complex case management
• Working knowledge of NCQA PHM standards
• Proficiency with Microsoft Office tools (Word, Excel, Outlook, PowerPoint)
• Solid organizational, multi tasking, and change management skills
• Excellent critical thinking, analytical, and problem-solving skills with strong attention to detail
• Ability to work independently with minimal supervision
• Solid  written and verbal communication skills
• Ability to work 8 hours within the hours of 7:30am-5:30pm CST

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN), Healthcare Administration, or related field
• CCM (Certified Case Manager) or CPHQ (Certified Professional in Healthcare Quality) certification
• Audit, training, quality, or leadership experience
• Experience supporting health plan or MSO quality audits, compliance, or accreditation efforts
• Experience working in Curo case management system
• Solid knowledge of Medicare Advantage programs and CMS standards

Key Competencies:

• Attention to detail and accuracy
• Critical thinking and clinical judgment
• Collaboration and relationship building
• Ability to educate providers or administrative staff and provide feedback constructively on performance
• Adaptability and comfort with change

*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.

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.

OptumCare 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.

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