Director Clinical Administration RN - Albuquerque, NM

Careers at UnitedHealth Group

We're creating opportunities in every corner of the health care marketplace to improve lives while we're building careers. At UnitedHealth Group, we support you with the latest tools, advanced training and the combined strength of high caliber co-workers who share your passion, your energy and your commitment to quality. Join us and start doing your life's best work. SM


Compassion. It's the starting point for health care providers like you and it's what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you're also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life's best work. SM

Our teams are helping people from around the world. We can bring out your best as you put your listening, analytical and problem solving skills to work in a setting that is geared to helping improve lives and enhance health care for millions. Here, you'll discover a wealth of pathways for professional growth within Customer Service, Billing, Claims, Enrollment & Eligibility and across our global economy. Join us and find out why this is the place to do your life's best work. SM

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

The Director of Clinical Administration RN is responsible for delivering clinical and operational insight to executives on core elements of the organization's long-term strategy, as well as the shorter term needs of the organization. Provide support to the CMO and CNO on short- or long-term projects. Adheres to policies, procedures and regulations to ensure compliance and patient safety. Participation in Compliance and other important training is a condition of employment.

Primary Responsibilities:
  • Clinical Interface/Liaison (clinical problem solver with facilities, providers, carriers; resolution of issues concerning members, benefit interpretation, program definition and clarification)
  • Clinical Operations Analysis (monitors and analyzes medical management activities; provides analytical support to clinical programs; may perform clinical assessments and clinical audits)
  • Clinical Training (planning, coordinating, delivering and evaluating clinical training)
  • Clinical Writing (writing nursing tools and reference information to support the design of clinical products and services)
  • Clinical Program Management (development, implementation and/or on-going management and administration of a clinical program(s). Provides strategic oversight and support, measurement standards and revisions as needed for delivery of programs focused on quality, affordability and outcomes)
  • Sets team direction, resolves problems and provides guidance to members of own team
  • Oversee work activities of other supervisors
  • Develops and adapts departmental plans and priorities to address business and operational challenges.
  • Influences or provides input to forecasting and planning activities
  • Product, service or process decisions are most likely to impact multiple groups of employees and/or customers (internal or external)
  • Manages and is accountable for professional employees and/or supervisors
  • Respond to Clinical Questions and/or Provide Clinical Information
    • Educate others regarding guidelines (e.g., Milliman Care Guidelines, CMS), criteria, and procedures (e.g., cases that meet expedited review guidelines, training internal staff)
    • Screen or respond to customer requests (e.g., expedited review, training requests, questions regarding rules/guidelines)
    • Provide feedback/information to internal or external customers (e.g., trends, feedback on prevention of errors, communication of findings)
    • Educates others around new or existing regulatory requirements
    • Find answers to basic questions and determine what other information could provide a more complete understanding of the situation
  • Collect, Review, and Summarize Clinical Information
    • Leverage technology including on-line resources (e.g., Internet sites, internal websites) or other internal systems (e.g., claims processing system, care management document systems) to research information, understand/define information provided (e.g., help members identify services, identify healthplan coverage, navigate websites), and document information.
    • Identify information and records that are needed based on the situation and request or find information
    • Obtain information from appropriate stakeholders (members, clinicians, internal staff)
    • Review detailed clinical information, analyze and interpret clinical documentation, determine relevance, and make clinically sound conclusions (e.g., for appeals, care management, regulatory, clinical risk management)
    • Present findings of clinical or other reviews (e.g., Medicare payment accuracy, training needs) to relevant parties and/or send summary information to others for review
    • Review work and/or respond to findings and identify/correct errors to ensure accurate information is presented or documented (e.g., quality audits/reviews)
    • Develop action plans based on clinical review/findings/audits
  • Demonstrate Business/Industry Knowledge
    • Demonstrate knowledge of healthcare insurance industry products and regulations (e.g., HMO, Medicare, Medicaid)
    • Demonstrate knowledge of applicable regulatory requirements (e.g., OSHA, HIPAA, CMS, vendor compliance, DOI, DMHC)
    • Demonstrate knowledge of nursing functions within the healthcare insurance industry (e.g., utilization review procedures, case management, appeals and grievance procedures)
    • Demonstrate knowledge of applicable area of specialization (e.g., training, appeals, interface/liaison, operations analysis, clinical writing)
    • Demonstrate knowledge of managed care models (e.g., IPA, group practice)
  • Ensure Compliance with Relevant Processes, Procedures, and Regulations
    • Identify relevant internal policies and regulatory guidelines
    • Ensure compliance with clinical guidelines
    • Establish/follow compliance procedures and enforce regulations and guidelines
    • Complete applicable documentation (e.g., draft letters of denial/approval, member/provider contacts) following relevant internal and external regulations and guidelines
    • Follow departmental processes (e.g., workflows, job aids)
    • Write and/or enforce policies to minimize risk and meet external regulatory requirements
  • Drive Effective Clinical Decisions within a Business Environment
    • Demonstrate understanding of business implications of clinical decisions (e.g., financial ramifications)
    • Ask critical questions to ensure member/customer centric approach to work
    • Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
    • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
    • Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes and financial performance
    • Use appropriate business metrics (e.g. member/FTE, length of stay, readmission rates, STAR ratings, member engagement rates) and applicable processes/tools (e.g. cost benefit analysis, return on investment, performance, staffing calculator) to optimize decisions and clinical outcomes
    • Prioritize work based on business algorithms and established work processes, or in their absence, identify business priorities and build consensus to triage and deliver work (e.g. assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up.)
    • Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state)

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:
  • Bachelor's Degree in a related field or equivalent experience
  • 7+ years of job-related experience, 3+ years of which are in the health care industry
  • Skilled at benchmarking, data gathering, data mining skills
  • Ability to compile complex reports and develop presentations

Preferred Qualifications:
  • Master's Degree in related field
  • Current, unrestricted nursing license (i.e. RN, LPN, LVN) in the applicable state
  • Ability to counsel and/or consult and to lead work teams
  • Excellent communication and interpersonal skills
  • Excellent analytical and problem-solving skills

Physical Demands:
  • Continuously sitting
  • Occassionally standing and walking

UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status.

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care 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)

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and 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.

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

Job Keywords: RN Director, Nurse, Director, Practice Health and Safety, Albuquerque, NM, New Mexico