Optum Clinical Review Jobs (NOW HIRING)

Optum Home & Community Care, part of the Optum family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere. As a team member of our Senior Community Care (SCC) team, we work to provide care to patients in nursing homes, senior housing and assisted living settings. This life-changing work adds a layer of support to improve access to care. We're connecting care to create a seamless health journey for patients across settings. Join us to start Caring. Connecting. Growing together.

The Clinical Advisor is responsible for managing up to approximately one half a case load and for providing mentoring, coaching and support for APCs and RNs in the field. The Clinical Advisor partners with their Clinical Services Manager (CSM), Clinical Team Lead (CTL) or Director of Clinical Operations (DCO) to enhance clinical expertise and adherence to Optum's clinical model.

• Set team direction, resolve problems, and provide guidance to members of own team
• Adapt departmental plans and priorities to address business and operational challenges
• Clinically mentor/teach team members as appropriate under the direction of CSM
• Maintain caseload of 50% or more patients and acquire patients according to team needs in conjunction with clinical advisor duties
• The CA reports to and is supported by the CSM, CTL, or DCO
• Partner with the manager or supervisor to ensure effective on-boarding of new clinicians and ongoing development of existing clinicians
• Develop innovative approaches and support the implementation and adoption of new clinical and quality initiatives
• Does not have direct reports but works in coordination with the CTL, CSM, and/or DCO to enhance clinical expertise and adherence to the clinical model through planning and implementing the orientation and development of APC staff
• Utilize advanced clinical nursing expertise, knowledge of geriatric/chronic disease management, and the long-term care industry to provide coaching, mentoring, and role-modeling to new and existing clinicians
• Oversee and implement clinical staff development programs in collaboration with market leadership
• Review work performed by others and provides recommendations for improvement in conjunction with supervisor
• Serve as a resource to APCs/RNs for escalated complex and/or clinical issues
• Partner with clinicians and other site functions to ensure business development activities are in place to meet business goals
• Sought out as knowledge-based expert
• Communicate needs and issues surfaced by clinical staff to site and corporate leadership
• Serve as a leader/mentor
• Promote the development of a collegial team, for coverage, troubleshooting and brainstorming
• Foster and develop a culture of clinical expertise
• Anticipate customer needs and proactively develop solutions to meet them
• Solve complex problems and develop innovative solutions in collaboration with other stakeholders
• Perform complex conceptual analyses
• Forecast and plan resource requirements
• Authorize deviations from standards
• May lead functional or segment teams and/or projects
• Provide explanations and information to others on complex issues
• Motivate and inspire other team members

• Deliver cost-effective, quality care to assigned members
• Manage both medical and behavioral chronic and acute conditions effectively in collaboration with a physician or specialty provider
• Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations
• Ensuring that all diagnoses are accurate and support the documentation for that visit
• The APC is responsible for ensuring that all quality elements are addressed and documented
• The APC will do an initial medication review, annual medication review and a post-hospitalization medication reconciliation
• Facilitate agreement and implementation of the member's plan of care by engaging the facility staff, families/responsible parties, primary and specialty care physicians
• Evaluate the effectiveness, necessity and efficiency of the plan, making revisions as needed
• Utilizes practice guidelines and protocols established by CCM
• May be required to participate in on-call program
• Travel between care sites mandatory
• After hour on call coverage may be required

• Understand the Payer/Plan benefits, CCM associate policies, procedures and articulate them effectively to providers, members and key decision-makers
• Assess the medical necessity/effectiveness of ancillary services to determine the appropriate initiation of benefit events and communicate the process to providers and appropriate team members
• Coordinate care as members transition through different levels of care and care settings
• Continually monitor the needs of members and families while facilitating any adjustments to the plan of care as situations and conditions change
• Review orders and interventions for appropriateness and response to treatment to identify most effective plan of care that aligns with the member's needs and wishes
• Evaluate plan of care for cost effectiveness while meeting the needs of members, families and providers to decreases high costs, poor outcomes and unnecessary hospitalizations

• Regular and effective communication with internal and external parties including physicians, members, key decision-makers, nursing facilities, CCM staff and other provider groups
• Actively promote the CCM program in assigned facilities by partnering with key stakeholders (i.e.: internal sales function, provider relations, facility leader) to maintain and develop membership growth
• Exhibit original thinking and creativity in the development of new and improved methods and approaches to concerns/issues
• Function independently and responsibly with minimal need for supervision
• Demonstrate initiative in achieving individual, team and organizational goals and objectives
• Participate in CCM quality initiatives

• Personal and Professional Accountability:
  • Create an environment that facilitates the team to initiate actions that produce positive results
  • Ability to hold self and others accountable for actions and results in collaboration with CSM/CTL/DCO
  • Answers for one's own behavior and actions
• Career Planning:
  • Develops own career path
  • Coach others in the development of their career planning
• Ethics:
  • Integrate high ethical standards and UHG core values into everyday work activities

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:

• Certified Nurse Practitioner through a national board
• For NPs: Graduate of an accredited master's degree in Nursing (MSN) program or doctor of nursing practice (DNP) program and board certified through the American Academy of Nurse Practitioners (AANP) or the American Nurses Credentialing Center (ANCC), Adult-Gerontology Acute Care Nurse Practitioners (AG AC NP), Adult/Family or Gerontology Nurse Practitioners (ACNP), with preferred certification as ANP, FNP, or GNP
• Active and unrestricted license in the state which you reside
• Current active DEA licensure/prescriptive authority or ability to obtain post-hire, per state regulations (unless prohibited in state of practice)
• 1+ years of experience as an APC at Optum
• Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area
• Ability to move a 30-pound bag in and out of car and to navigate stairs and a variety of dwelling conditions and configurations
• Ability to gain a collaborative practice agreement, if applicable in your state

Preferred Qualifications:

• 2+ years of experience as an APC
• 1+ years Medicare experience
• Experience in adult teaching environment
• Ability to develop and maintain positive customer relationships
• Possess knowledge and understanding of geriatrics clinical management
• Ability to work across functions and businesses to achieve business goals