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Remote Optum Clinical Review Jobs in Virginia (NOW HIRING)

Siemens Healthineers

$134K - $184K/yr

Post-market clinical follow-up activities and clinical review of promotional materials are also key responsibilities. This is remote role in the US and Canada with less than 25% travel requirements ...

Sentara Healthcare

Authorization Coordinator

Norfolk, VA · On-site +1

$18 - $22.25/hr

The Authorization Coordinator is responsible for review of clinical information received from ... For positions that are available as remote work, Sentara Health employs associates in the following ...

Sentara Healthcare

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site +1

... policy, clinical criteria). Facilitates accreditation by knowing, understanding, correctly ... For positions that are available as remote work, Sentara Health employs associates in the following ...

IQVIA

Clinical Trial Psych Rater

Fairfax, VA · Remote

$62K - $156K/yr

Remote/Virtual Hours: Estimated 10-16 hours per month Role: Clinical Specialist About IQVIA IQVIA ... This position involves reviewing scales administered by raters to confirm standardized assessment ...

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Remote Optum Clinical Review information

What is a Remote Optum Clinical Review?

A Remote Optum Clinical Review is a job where healthcare professionals, such as nurses or physicians, evaluate medical records and treatment plans from a remote location. The goal is to ensure that healthcare services and procedures meet established clinical guidelines and are medically necessary. These reviews help determine coverage decisions for insurance claims and improve patient outcomes. Team members work from home, using secure systems to review documentation and collaborate with clinicians or insurance representatives. Optum is a part of UnitedHealth Group, and their clinical reviewers play a key role in maintaining quality and compliance in healthcare delivery.

How does a Remote Optum Clinical Review professional typically collaborate with interdisciplinary teams while working from home?

Remote Optum Clinical Review professionals frequently collaborate with physicians, nurses, case managers, and other healthcare staff through virtual meetings, secure messaging, and shared electronic health records. Effective communication skills are essential, as most interactions are conducted remotely. Team members regularly participate in cross-functional discussions to review patient cases, ensure compliance with clinical guidelines, and make evidence-based recommendations. Despite working from home, there is a strong emphasis on teamwork and maintaining alignment with organizational goals and regulatory standards.

What are the key skills and qualifications needed to thrive as a Remote Optum Clinical Review nurse, and why are they important?

To thrive as a Remote Optum Clinical Review Nurse, you need a valid RN license, strong clinical judgment, and experience in utilization management or case review. Familiarity with clinical review software, electronic health records (EHRs), and knowledge of medical necessity criteria like MCG or InterQual is typically required. Excellent attention to detail, critical thinking, and effective communication are key soft skills for evaluating cases and collaborating with healthcare teams. These skills ensure accurate clinical assessments, compliance with regulations, and improved patient care outcomes in a remote environment.

What is the difference between Remote Optum Clinical Review vs Remote Optum Utilization Review?

AspectRemote Optum Clinical ReviewRemote Optum Utilization Review
CertificationsRN, LPN, or other clinical licensesRN, LPN, or other clinical licenses
Work EnvironmentHome-based, healthcare settingHome-based, healthcare setting
Employer & IndustryOptum, healthcare insurance and managed careOptum, healthcare insurance and managed care
Primary FocusAssessing clinical necessity and appropriateness of careReviewing medical necessity for insurance coverage

Both roles involve remote work within the healthcare insurance industry, requiring clinical licenses. The main difference is that Clinical Review focuses on evaluating the appropriateness of care, while Utilization Review emphasizes determining medical necessity for insurance purposes.

What are the most commonly searched types of Optum Clinical Review jobs in Virginia?

The most popular types of Optum Clinical Review jobs in Virginia are:

What are popular job titles related to Remote Optum Clinical Review jobs in Virginia?

For Remote Optum Clinical Review jobs in Virginia, the most frequently searched job titles are:

What job categories do people searching Remote Optum Clinical Review jobs in Virginia look for?

The top searched job categories for Remote Optum Clinical Review jobs in Virginia are:

What cities in Virginia are hiring for Remote Optum Clinical Review jobs?

Cities in Virginia with the most Remote Optum Clinical Review job openings:

Remote Optum Clinical Review jobs near you

Remote Cardiology, Physician Clinical Reviewer

Evolent

Arlington, VA • On-site, Remote

Other

Posted 27 days ago

Evolent rating

8.4

Company rating: 8.4 out of 10

Based on 18 frontline employees who took The Breakroom Quiz

73rd of 499 rated business services

Job description

As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes.



Collaboration Opportunities:  


  • Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required. As well as, aids and acts as a resource to Initial Clinical Reviewers.



What You Will Be Doing:


  • Serve as the specialty match reviewer in Cardiology cases, that do not initially meet the applicable medical necessity guidelines, as well as other requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.

  • Provides clinical rationale for standard and expedited appeals.

  • Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request.

  • Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines.

  • Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.

  • Participates in on-going training per inter-rater reliability process.

  • May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.

  • On a requested basis, may function as Medical Director for selecting health plans or regions, assuming overall accountability for utilization management while working in conjunction with the Senior Medical Director.



Qualifications - Required and Preferred:


  • MD/DO/MBBS Degree

  • Current, unrestricted clinical license in medicine or required specialty

  • Obtaining and maintaining medical licenses in the state you reside, as well as, other state licensure required per business needs

  • Active Board Certification in Cardiology, Vascular Surgery or Adult Congenital Heart Disease

  • Strong clinical, management, communication, and organizational skills

  • Energetic and curious with a passion for quality and value in health care

  • Computer Proficiency

  • Minimum of five (5) years’ experience in the practice of Cardiology is preferred

  • Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.

  • No history of a major disciplinary or legal action by a state medical board

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