Remote RN Senior Clinical Quality Consultant Compact Lics CST TX AL


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Requisition Number: 2230911
Job Category: Nursing
Primary Location: San Antonio, TX
(Remote considered)

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. 

The WellMed Quality Clinical Programs team supports WellMed Medical Management by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close STARs measure gaps in care, e.g. medication adherence, care for older adults, medication reconciliation post discharge, A1c, etc. Our interdisciplinary service delivery team is comprised of Registered Nurses, Licensed Vocational Nurses, and Social Workers.


The Registered Nurse will report into the Manager of Clinical Programs. The Registered Nurse will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. In addition, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work a flexible schedule to support the hours of operation of the business


You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Must have a compact lics and willing to support CST


Primary Responsibilities: 

  • Strictly adheres to department’s metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests
  • Primarily to make outbound calls but occasionally help manage the inbound call queue from patients, patient representatives, providers and other medical staff, while strictly adhering to established protocols and scripting
  • Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services
  • Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments
  • Educate patients on health conditions and necessity of route screening but assisting with appointment scheduling (A1c, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.)
  • Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided
  • Review available medical records for core measures to submit for closure of HEDIS/STARS measures
  • Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs, (Pharmacy assistance programs, meals on wheels, LIS)
  • Document thoroughly all calls and actions taken within core systems
  • Hours of Operations: Mon-Fri 9am-6pm Central and Required Rotating – Saturdays 8am-5:30pm Central.
  • Performs all other related duties as assigned


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: 

  • Active, unrestricted Registered Nurse license
  • Must have Compact Lics and willing to support CST
  • 4+ years of RN experience, including experience in a managed care setting
  • 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role.
  • 2+ years of call center experience
  • 2+ years of experience with data analysis and/or quality chart reviews. Must be able to review paper and electronic medical records and charts
  • Proven solid knowledge of the Medicare HEDIS/Stars measures
  • Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels
  • Ability to manage multiple complex, concurrent projects
  • Proven excellent written and verbal communication and relationship building skills
  • Demonstrated solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
  • Experienced using Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets. Must be proficient in Excel
  • Proven excellent customer service skills and communication skills


Preferred Qualifications: 

  • Undergraduate degree or post graduate degree
  • Billing and CPT coding experience
  • Clinical data abstraction experience
  • Proven adaptable to change
  • Proven good business acumen, especially as it relates to Medicare

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

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $70,200 to $137,800 annually. 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.