At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together As a Clinical Grievances Nurse, you will be responsible for reviewing incoming retrospective cases to determine if the appropriate care was given along with current cases to ensure the members immediate needs are being addressed. In providing consumer - oriented health benefit plans to millions of people; our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system. If you are able to work PST hours, you will have the flexibility to work remotely* as you take on some tough challenges. The working hours for this role are Monday - Friday, 8 am - 5pm PST. Primary Responsibilities: • Perform clinical assessment of healthcare services provided to our members for appropriateness • Understand relevant state and federal grievance and peer review requirements and accreditation standards applicable for processes supported • Receives cases from the QIS non- clinical team and reviews them against required clinical information, assessing for appropriateness and consulting with a Medical Director • Document relevant chronology of case review and provide rationale for severity level, descriptor codes, and any applicable Improvement Action Plan (IAP) implemented • Facilitate telephonic discussion with health care providers and/or members to obtain additional clinical information • Provide timely, quality service to members and providers while upholding UnitedHealthcare culture values • Act as a resource for others with less experience • Work independently and collaborating with Medical Directors and non-clinical partners • Function as a member of a self-directed team to meet specific individual and team performance metrics • Manage and maintain quality and productivity metrics 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.
Optum Home & Community Care is part of UnitedHealth Group and provides telephonic case management services to help members navigate the health care system and access support services. As an RN Case Manager, you would assess members' health status, identify gaps in treatment plans, establish care goals, coordinate with multidisciplinary teams including mental health clinicians, provide patient education and coaching, make referrals to community resources, and facilitate transitions between care settings—primarily through phone calls in a high-volume customer service environment.
