UnitedHealth Group Clinical Quality Auditor - Telecommute in Los Angeles, California

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)

Local Care Delivery is a network of health care providers in local markets whose mission is to help providers deliver the most effective and compassionate care to each patient they serve. Local Care Delivery’s primary focus is on doing the right things for patients, physicians, and the community. It uses an innovative service model focused on measuring what matters and increasing efficiency and performance while providing the highest level of customer service. This model allows LCD to make a difference each day by delivering highly personal, customized care management to its patients.

The Clinical Quality Nurse performs clinical quality audits and peer reviews of prior authorization and medical claims review case work to evaluate compliance with department policies and regulatory requirements.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

  • Evaluate pre-certification case review and medical claims case review to determine/verify whether or not medical necessity criteria were met using industry guidelines (CMS, Health Plan policies, MCG

  • 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)

  • Verify if outreach for additional information was required and followed regulatory guidelines

  • Run/pull/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 case review staff to improve/standardize pre-service and post-service case review

  • Identify and report quality of care concerns appropriately

  • Report inconsistencies/problems with prior authorization 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

Required Qualifications :

  • Unrestricted Registered Nursing License

  • 2+ years of experience in medical necessity or utilization management/review

  • Minimum of 2 years claims review post service

  • Minimum of 3 years prior authorization experience

  • Experience in auditing or training of clinical and non-clinical teams

  • Excellent written and verbal communication skills

Preferred Qualifications:

  • Experience in managed care setting (handling Medicare patients from a case management or utilization management perspective)

  • Experience with clinical criteria (MCG or InterQual)

  • Experience in data analysis and reporting

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Diversity creates a healthier atmosphere: 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.


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

Job Keywords: Clinical, Quality, Analyst, Nurse, RN, auditing, auditor, medical necessity, utilization management, telecommute, telecommuting, telecommuter, work from home, remote