At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

If you are located in or near the District of Columbia, you will have the flexibility to work in a hybrid model (2-3 days in the office) as you take on some tough challenges.

Primary Responsibilities:

The UnitedHealthcare Community Plan of DC proudly serves the Dual Eligible Special Needs (D-SNP) population in the District of Columbia and is excited to recruit for our leader of clinical oversight. This individual contributor will report directly to the Executive Director and will support them on coordinating select priorities, as well as have accountability in two key areas:

• Utilization Management: Oversight of all utilization management functions for the health plan, including areas such as:
  • Supporting the strategy, as well as overseeing and improving trends, in prior authorizations, over/under-utilization, quality improvement, etc. This includes collaboration with other functional areas, such as pharmacy, behavioral health, dental, etc.
  • Managing processes relating to Appeals & Grievances, including the State Fair Hearing process
  • Owning contractually required deliverables, including audits and committee management
• Clinical Operations: Thoughtfully collaborate with the clinical team and broader health plan functions to drive and improve clinical priorities by:
  • Developing, implementing, and monitoring clinical priorities defined by the Executive Director and Chief Medical Officer
  • Identifying and analyzing clinical data to drive clinical outcomes and/or measures and improve processes
  • Providing suggestions on improvements that will better meet member needs, including supporting training opportunities

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:

• Registered Nurse currently licensed to practice in the District of Columbia
• 2+ years of experience in utilization management (authorization, notice of action, appeals, etc.)
• 2+ years of experience in experience in Medicaid programs, D-SNP programs and/or Managed Care Organizations (MCOs)
• Intermediate or higher level of proficiency with MS Office (Word, Outlook, PowerPoint)
• Resides in the District of Columbia, Maryland or Virginia

Preferred Qualifications:

• Experience in project management, program management and/or event management
• Experience and knowledge of health care and managed care delivery systems, including quality improvement and utilization mgmt. processes, medical practice standards and insurance benefit structures
• Demonstrated ability to proactively problem-solve and navigate in a fast-paced, changing environment
• Demonstrated ability to communicate (verbally/written) effectively with different levels of leadership
• Demonstrated ability to be detail-oriented and develop executive-level content or presentations

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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.