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Clinical Nurse Navigator Medicare Advantage Risk and Care Integration RN Remote in EST
Opportunities with ProHealth Physicians, part of the Optum family of businesses. When you work at ProHealth Physicians, your contributions directly sustain the health and well-being of our community. Discover high levels of teamwork, robust medical resources and a deep commitment to exceptional care and service. Join a leading community-based medical group and discover the meaning behind Caring. Connecting. Growing together.
The Clinical Nurse Navigator supports Optum's value based care and Medicare Advantage programs by integrating clinical expertise, member engagement, and documentation integrity. This role serves as a clinical liaison across members, providers, internal teams, and vendor partners to ensure accurate chronic condition capture, closed loop care coordination, and improved quality and risk adjustment outcomes.
The Clinical Nurse Navigator performs RN level validation of Hierarchical Condition Categories (HCCs), reduces reliance on external vendor over read services, and ensures timely follow up on conditions, orders, referrals, and preventive care gaps. Through proactive member navigation and provider collaboration, this role helps strengthen care continuity, optimize clinical documentation, and support Optum's commitment to delivering high quality, cost effective, and member centered care.
If you are located in EST, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
- Clinical Documentation Integrity & Risk Adjustment
- Perform RN level review of clinical documentation to validate chronic condition capture and appropriate HCC support
- Identify and address missed, unsupported, or inaccurately documented diagnoses
- Closed Loop Care Coordination
- Ensure closed loop follow up on identified condition screening and care gaps identified during AWV
- Collaborate with members and care teams to address barriers to care completion
- Member Navigation & Engagement
- Support new Medicare Advantage member engagement
- Facilitate connection to the attributed Care Team
- Promote continuity of care and participation in preventive and wellness programs
- PCP Attribution & Care Alignment
- Facilitate and validate PCP attribution corrections to ensure accuracy and alignment with member care
- Collaborate with operational partners to resolve attribution discrepancies
- Vendor Collaboration & Oversight
- Review vendor clinical documentation for accuracy, completeness, and clinical appropriateness
- Provide feedback and insights to support vendor quality and performance improvement
- Reporting & Performance Insights
- Contribute to monthly reporting related to documentation integrity and member engagement
- Provide actionable insights to leadership and cross functional partners
Required Qualifications:
- Current, unrestricted Registered Nurse (RN) license in Connecticut (CT), New York (NY), or New Jersey (NJ)
- Ability to obtain and maintain active licensure in the remaining states upon hire
- 5+ years of clinical practice experience
- Reside within the Eastern Standard Time Zone
- Experience working in a provider based or physician (MD) office setting
- Proficiency with Microsoft Office applications, including Word, Outlook, Excel, and PowerPoint
- Demonstrated ability to apply clinical judgment across medical records, workflows, and care settings
- Bachelor of Science in Nursing (BSN)
- Experience supporting Medicare Advantage Risk Adjustment
- Billing and coding experience and/or medical office management experience
- Solid understanding of coding principles, including ICD 10 and documentation requirements
- Proven solid facilitation, consulting, and communication skills, with the ability to deliver complex clinical and operational information to diverse audiences
- All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
