[Hiring] Clinical Quality RN @UnitedHealth Group

Role Description

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

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.

Qualifications

• Current, unrestricted Registered Nurse (RN) license in a Compact state.
• 2+ years of managed care experience, including at least 1 year 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.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

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.