Job was saved successfully.
Job was removed from Saved Jobs.

Job Details

UnitedHealth Group

Clinical Administrator Coordinator - RN (Remote - EST Timezone)


Clinical Coordinator


Charlotte, North Carolina, United States

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

Positions in this family require a current, unrestricted nursing license (i.e. RN, LPN, LVN) in the applicable state, as indicated in the function description and/or job title.

Positions in this function include RN roles (with current unrestricted licensure in applicable state) responsible for providing clinical expertise in any of the following areas:

  • Clinical Interface/Liaison (clinical problem solver with facilities, providers, carriers; resolution of issues concerning members, benefit interpretation, program definition and clarification)
  • Clinical Operations Analysis (monitors and analyzes medical management activities; provides analytical support to clinical programs; may perform clinical assessments and clinical audits)
  • Clinical Training (planning, coordinating, delivering and evaluating clinical training)
  • Clinical Writing (writing nursing tools and reference information to support the design of clinical products and services)
  • Clinical Program Management (development, implementation and/or on-going management and administration of a clinical program(s). Provides strategic oversight and support, measurement standards and revisions as needed for delivery of programs focused on quality, affordability and outcomes)

General Job Profile

  • Generally work is self-directed and not prescribed
  • Works with less structured, more complex issues
  • Serves as a resource to others

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

Primary Responsibilities:

  • Assesses and interprets customer needs and requirements
  • Identifies solutions to non-standard requests and problems
  • Solves moderately complex problems and/or conducts moderately complex analyses
  • Works with minimal guidance; seeks guidance on only the most complex tasks
  • Translates concepts into practice
  • Provides explanations and information to others on difficult issues
  • Coaches, provides feedback, and guides others
  • Acts as a resource for others with less experience
  • Requires current unrestricted RN licensure in applicable state

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:

  • Undergraduate degree or equivalent experience
  • Compact Nursing License - NLC
  • Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Functional Competencies

Functional Competency & Description Proficiency Level

  • Educate others regarding guidelines (e.g., Milliman Care Guidelines, CMS), criteria, and procedures (e.g., cases that meet expedited review guidelines, training intemal staff)
  • Screen or respond to customer requests (e.g., expedited review, training requests, questions regarding rules/guidelines)
  • Provide feedback/information to internal or external customers (e.g., trends, feedback on prevention of errors, communication of findings)
  • Educates others around new or existing regulatory requirements
  • Find answers to basic questions and determine what other information could provide a more complete understanding of the situation CAD_Collect, Review, and Summarize Clinical Information | C) Fully Proficient
  • Leverage technology including on-line resources (e.g., Internet sites, internal websites) or other internal systems (e.g., claims Processing system, care management document systems) to research information, understand/define information provided (e.g., help members identify services, identify healthplan coverage, navigate websites), and document information
  • Identify information and records that are needed based on the situation and request or find information
  • Obtain information from appropriate stakeholders (members, clinicians, internal staff)
  • Review detailed clinical information, analyze and interpret clinical documentation, determine relevance, and make clinically sound conclusions (e.g., for appeals, care management, regulatory, clinical risk management)
  • Present findings of clinical or other reviews (e.g., Medicare payment accuracy, training needs) to relevant parties and/or send summary information to others for review
  • Review work and/or respond to findings and identify/correct errors to ensure accurate information is presented or documented (e.g., quality audits/reviews)
  • Develop action plans based on clinical review/findings/audits
  • Demonstrate knowledge of healthcare insurance industry products and regulations (e.g.. HMO, Medicare, Medicaid)
  • Demonstrate knowledge of applicable regulatory requirements (e.g., OSHA, HIPAA, CMS, vendor compliance, DOI, DMHC)
  • Demonstrate knowledge of nursing functions within the healthcare insurance industry (e.g., utilization review procedures, case management, appeals and grievance procedures)
  • Demonstrate knowledge of applicable area of specialization (e.g., training, appeals, interface/liaison, operations analysis, clinical writing)
  • Demonstrate knowledge of managed care models (e.g., IPA, group practice)
  • Identify relevant internal policies and regulatory guidelines
  • Ensure compliance with clinical guidelines
  • Establish/follow compliance procedures and enforce regulations and guidelines
  • Complete applicable documentation (e.g., draft letters of denial/approval, member/provider contacts) following relevant internal and extemal regulations and guidelines
  • Follow departmental processes (e.g., workflows, job aids)
  • Write and/or enforce policies to minimize risk and meet external regulatory requirements
  • Demonstrate understanding of business implications of clinical decisions (e.g., financial ramifications)
  • Ask critical questions to ensure member/customer centric approach to work
  • Identify and consider appropriate options to mitigate issues related to quality, safety or affordability wnen they are identified, and escalates to ensure optimal outcomes, as needed
  • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
  • Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes and financial performance
  • Use appropriate business metrics (e.g. member/FTE, length of stay, readmission rates, STAR ratings, member engagement rates) and applicable processes/tools (e.g. cost benefit analysis, return on investment, performance, staffing calculator) to optimize decisions and clinical outcomes
  • Prioritize work based on business algorithms and established work processes, or in their absence, identify business priorities and build consensus to triage and deliver work (e.g. assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up.)
  • Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state)

Values Based Competencies

  • Employee
    • Integrity Value: Act Ethically
      • Comply with Applicable Laws, Regulations and Policies
      • Demonstrate Integrity
    • Compassion Value: Focus on Customers
      • Identify and Exceed Customer Expectations
      • Improve the Customer Experience
    • Relationships Value: Act as a Team Player
      • Collaborate with Others
      • Demonstrate Diversity Awareness
      • Learn and Develop
    • Relationships Value: Communicate Effectively
      • Influence Others
      • Listen Actively
      • Speak and Write Clearly
    • Innovation Value: Support Change and Innovation
      • Contribute Innovative Ideas
      • Work Effectively ina Changing Environment
    • Performance Value: Make Fact-Based Decisions
      • Apply Business Knowledge
      • Use Sound Judgement
    • Performance Value: Deliver Quality Results
      • Drive for Results
      • Manage Time Effectively
      • Produce High-Quality Work

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers with OptumRx. We're one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you’ll fill far more than prescriptions. As a member of one of our pharmacy teams, you’re empowered to be your best and do whatever it takes to help each customer. You'll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There's no better place to help people live healthier lives while doing your life's best work.(sm)

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

New York City, NY Residents Only: The salary range for New York City residents is $60,000 to $106,700. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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