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Clinical Quality RN - Pittsburgh, Philadelphia

UnitedHealth Group

Pittsburgh, PA
Job Code:
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Job Details

760829 Clinical Quality RN Pittsburgh Philadelphia

Clinical Quality RN - Pittsburgh, Philadelphia (760829)

Position Description

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)


If you are located in Philadelphia or Pittsburgh, PA, you will have the flexibility to telecommute* as you take on some tough challenges.


Primary Responsibilities:

  • Collaborate with appropriate department to document, investigate and resolve formal or informal member complaints and appeals in accordance with plan and state policies and procedures and requirements
  • Review and analyze reports, records, and medical documents/charts
  • Prepare reports and records on work function activities and projects
  • Coordinate quality management and HEDIS related programs and activities as required
  • Supports quality improvement programs requesting records from providers, maintaining databases, and researching to identify members' provider encounter history
  • Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned
  • Performs, provider and/or member outreach as required
  • Participates in or coordinates with other department projects as needed
  • Some travel to job related meetings and activities is required

Required Qualifications:

  • Clinical RN with current, unrestricted license in PA
  • 1 year of clinical experience
  • 1+ year working in managed care or in the insurance industry
  • Experience with Medicaid and/or Medicare
  • Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements
  • Experience with project coordination
  • Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint
  • Ability to evaluate medical records with attention to detail and prepare reports as needed

Preferred Qualifications:

  • 1+ year of experience working with Grievance and Appeals
  • Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance and achieve targets
  • Strong organizational skills and ability to interact with company staff at all level
  • Ability to do formal presentations in different settings-reporting on projects and reports that have been created and analyzed

Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place 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: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.


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



Job Keywords: RN, HEDIS , Quality, nurse, Quality improvement, Project management, project coordination, Appeals and Grievances,, NCQA, Medicare, Medicaid, Telecommute, Telecommuter, Telecommuting, Remote, Pittsburgh, Philadelphia, Pennsylvania, PA

Job Details

  • Contest Number760829
  • Job TitleClinical Quality RN - Pittsburgh, Philadelphia
  • Job FamilyNursing
  • Business SegmentCommunity and State

Job Location Information

  • Pittsburgh, PA
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelYes, 25 % of the Time
  • Telecommuter PositionYes
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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