Experienced Remote Clinical Quality Care Registered Nurse – Telecommute Opportunity with Advantage Plus Network of Connecticut

Introduction to Advantage Plus Network - Connecticut Imagine being part of a leading community-based medical group that is dedicated to providing exceptional care and service to its community. Advantage Plus Network - Connecticut, part of the Optum family of businesses, offers a unique opportunity for clinical professionals to make a meaningful difference in the lives of others. With a strong commitment to teamwork, robust medical resources, and a passion for delivering high-quality patient care, our organization is the perfect place for talented and compassionate individuals to grow and thrive. Job Overview: Remote Clinical Quality Care RN We are seeking an experienced and skilled Registered Nurse to join our Clinical Quality & Audit department as a Remote Clinical Quality Care RN. As a valued member of our team, you will be responsible for performing clinical quality audits and peer reviews of prior authorization, complex case management, transitions of care, disease management, and medical claims review case work. Your expertise will help ensure compliance with department policies and regulatory requirements, ultimately contributing to the delivery of exceptional patient care. Key Responsibilities: Evaluate medical management case work, including prior authorization, inpatient acute and post-acute, complex case management, transitions of care, and clinical claims, to determine whether medical necessity criteria were met using industry guidelines (CMS, Health Plan policies, MCG, NCQA) Verify that service providers were in-network or that a gap in network coverage was present Follow relevant regulatory guidelines, policies, and procedures in reviewing clinical case review documentation and medical necessity criteria selection (e.g., CMS, NCQA, HEDIS) Follow relevant regulatory guidelines, policies, and procedures in reviewing complex case management, transitional case management, and disease management, to ensure care planning process meets regulatory requirements (NCQA) Verify if outreach for additional information was required and followed regulatory guidelines Verify that required communication to members and providers was completed as required by regulatory requirements and department policies Run, pull, and prioritize relevant data/reports (e.g., case level data, audit trends, audit samples) Prioritize services for medical chart review (e.g., high volume or high-cost services) Manipulate and leverage multiple databases (e.g., provider panels, medical review databases) to sort, search, and enter information Identify incomplete/inconsistent information in case reviews and document missing criteria/documentation/concerns Provide guidance to clinical staff to improve/standardize case review Identify and report quality of care concerns appropriately Report inconsistencies/problems with prior authorization, admissions, case management, transitions of care, and/or medical claims case review to appropriate parties for resolution Direct activities/target learning to increase case review quality scores and improve case review processes Maintain HIPAA requirements for sharing minimum necessary information Essential Qualifications: Unrestricted current RN licensure in the state of residence 2+ years of experience in clinical case review or chart auditing using CMS, MCG, NCQA criteria 2+ years of experience in medical management while working in a remote setting Experience operating within multiple platforms that house case documentation and clinical records Proficient in Microsoft Office Proven excellent interpersonal and communication skills (both written and oral) Proven ability to work on a multi-disciplinary team Preferred Qualifications: Bachelor of Science, Nursing 5+ years of experience in medical management EMR experience (EPIC) Career Growth Opportunities and Learning Benefits At Advantage Plus Network - Connecticut, we are committed to helping our employees grow and develop in their careers. As a Remote Clinical Quality Care RN, you will have access to a range of training and development opportunities, including: Comprehensive onboarding program to ensure a smooth transition into your new role Ongoing training and education to help you stay up-to-date with the latest industry developments and best practices Opportunities for career advancement and professional growth within the organization Recognition and reward programs to recognize and reward your contributions and achievements Work Environment and Company Culture Our organization is built on a foundation of teamwork, respect, and compassion. We believe in creating a work environment that is supportive, inclusive, and empowering, where everyone has the opportunity to thrive and grow. As a Remote Clinical Quality Care RN, you will be part of a dynamic and dedicated team that is passionate about delivering exceptional patient care and making a positive impact in the community. Compensation, Perks, and Benefits We offer a competitive salary range of $58,300 to $114,300 annually, depending on experience and qualifications. In addition to your salary, you will also be eligible for a range of benefits, including: Comprehensive benefits package, including medical, dental, and vision coverage Incentive and recognition programs to recognize and reward your contributions and achievements Equity stock purchase and 401k contribution (subject to eligibility requirements) Opportunities for career advancement and professional growth within the organization Conclusion If you are a motivated and compassionate Registered Nurse looking for a new challenge and opportunity to make a difference in the lives of others, we encourage you to apply for this exciting role. As a Remote Clinical Quality Care RN with Advantage Plus Network - Connecticut, you will be part of a leading community-based medical group that is dedicated to delivering exceptional patient care and making a positive impact in the community. Don't miss out on this opportunity to join our team and take your career to the next level. Apply today and let's build the future together! We are an equal opportunity employer and welcome applications from diverse candidates. OptumCare 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. Apply for this job