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Senior Clinical Administrator RN

2 months ago


West Allis, Wisconsin, United States UnitedHealth Group Full time
Job Summary

We are seeking a highly skilled and experienced Registered Nurse to join our team as a Senior Clinical Administrator RN. This role will play a critical part in promoting wellness and good health habits among our employee population, while also coordinating with our Quad/QuadMed and UMR teams to deliver high-quality healthcare services.

Key Responsibilities
  • Promote wellness and good health habits among employees through various activities and interactions.
  • Identify high-risk and emerging risk members and engage with them to provide stabilization through ongoing one-on-one interactions.
  • Collaborate with the QuadMed Clinics to identify gaps in care and develop member-facing communication and activities.
  • Coordinate the delivery of healthcare services for high-risk and emerging risk members, ensuring engagement with specialists, timely initial and follow-up appointments, medication management, and compliance with treatment plans.
  • Identify and educate members utilizing non-QuadMed Urgent Care services to promote steerage back into the QuadMed Clinics for future Acute Care and encourage adoption of a Primary Care Provider.
  • Assist in steerage to Premium Designated Providers for Care as needed when not available at QuadMed.
  • Refer to and partner with the Case Management and UMR team as needed for Member engagement and participation in UMR programs.
  • Partner with the Quad/QuadMed team to facilitate engagement in appropriate Quad/QuadMed internal Health Programs, including but not limited to: Wellness, Behavioral Health, Pharmacy, etc.
  • Assess barriers to member engagement, care, and resources, and assist with community resources and support to help address identified barriers.
  • Act as a resource to members calling into a customer service setting, addressing medical/health questions.
  • Provide process and status on previously submitted prior authorizations or pre-determination requests.
  • Support and advocate for members and families in complicated medical situations.
  • Use good nursing judgment in a variety of scenarios in real-time.
  • Accurately document member interaction across multiple databases, following all processes and procedures.
  • Educate members in healthcare decision-making.
  • Assist with the development and implementation of departmental policies and procedures.
Requirements
  • Current and unrestricted compact Wisconsin RN license.
  • 2+ years of acute nursing experience as an RN.
  • Basic computer proficiency (e.g., MS Word, Outlook).
  • Ability to obtain multi-state licensure as required.
Preferred Qualifications
  • Case Management Certification (CCM).
  • 2+ years of managed care experience.
  • 2+ years of experience in employee wellness and/or health promotion.
  • Call center experience.
  • Clinical experience outside of the hospital setting.
  • Case management experience.
  • Experience in Oncology, Musculoskeletal, ER, and Discharge Planning.
Soft Skills
  • Demonstrated excellent verbal and written communication skills.
  • Excellent customer service orientation.
  • Proven team player and team building skills.
  • Ability and flexibility to assume responsibilities and tasks in a constantly changing work environment.