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WellMed, part of the Optum family of businesses, is seeking a RN Supervisor Medical Claim Review to join our team in Texas. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Supervisor of Clinical Medical Claim Review (MCR) is responsible for the supervision, evaluation and direction of the Utilization Compliance and Quality Management process. The position will ensure compliance with the medical necessity review of the UM Plan for retrospective and live claims. The position is a resource for difficult or complex retrospective cases, interpretation of medical regulations, and implementation of UM/MM initiatives. The supervisor successfully impacts assigned team and organization by mentoring those who wish advancement and engages in departmental process improvement, work cross-functionally with teams and lead MCR clinical activities. In addition, the Supervisor is responsible for timely completion of staff audits, department reports, while coaching and mentoring team members to meet and exceed all documented compliance standards. This position trains and reviews MCR clinical staff in the completion of timely and complaint processing of cases and functions as an advisor to Physicians and utilization management staff interfacing with the team.

This position requires working various shift hours and required rotating weekends.

If you have a Compact License, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Provides leadership and support in establishing and executing the MCR Initiatives in alignment with corporate goals

• Supervises and coordinates the work activities of the team

• Monitors productivity, metrics, documentation and call quality to ensure established standards are met

• Collaborates with physicians, utilization management and support staff to execute the implementation of the MCR initiatives as defined by the enterprise

• Work with internal market teams and external vendors on medical record and electronic medical record issues

• Monitor and analyze large volume within the clinical queues to ensure compliance with health plan contracts and federal and state regulations

• Analyze and trend cases reviewed and identify opportunities for end-to-end process improvement

• Update MCR templates, staff training materials, and Work Plans with assigned responsibilities

• Attend and participate in all MCR related meetings

• Performs all other related duties as assigned

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.

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:

• Professional Nursing Degree with current RN License (in state of employment)

• 5+ years of experience within a healthcare environment including experience within a managed care setting, including 3+ years of management experience

• 3+ years of experience with data analysis

• Utilization review experience; working knowledge of the managed care referral process, case management, claims, contracting, and physician practice (experience with managed risk in a healthcare risk-sharing arrangement)

• Advanced experience using Microsoft office applications, including but not limited to databases, word-processing, spreadsheets, and graphical displays

• Proven capability to work with people at all levels in an organization

• Proven excellent training and presentation skills with solid communication capabilities and practices, both oral and written

• Demonstrated effective organizational skills

• Proven excellent communication, writing, proofreading and grammar skills

• Proven solid attention to detail and accuracy, excellent Evaluative and Analytical skills

• Proven solid teamwork, interpersonal, verbal, written, and administrative and customer service skills

Preferred Qualifications:

• BSN degree or related field

• Medicare experience, especially Medicare Advantage

• Experience with managed care claims, especially in a production/inventory environment

Physical & Mental Requirements:

• Ability to lift up to 10 pounds

• Ability to push or pull heavy objects using up to 20 pounds of force

• Ability to sit for extended periods of time

• Ability to use fine motor skills to operate office equipment and/or machinery

• Ability to receive and comprehend instructions verbally and/or in writing

• Ability to use logical reasoning for simple and complex problem solving

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

The salary range for this role is $71,600 to $140,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

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