Clinical Nurse Navigator Medicare Advantage Risk and Care Integration RN Remote in EST

UnitedHealth Group•Boston, MA

1d•Remote

About The Position

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.

Requirements

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

Nice To Haves

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

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