Optum ยท 23 hours ago
Clinical Consultant Analyst - Remote
United States
Full-time
Remote
Mid, Senior Level
$73K/yr - $130K/yr
5+ years expOptum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The Clinical Consultant Analyst is responsible for reviewing large claim notices to identify potential risks and educating stakeholders about clinical trends, while also assessing opportunities for cost containment.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Review and assess large claim notices for potential risks. (approx. 25%)
Set-up potential large dollar claimants in POWER for ongoing risk assessment and allocation of reserves
Continue to follow these claimants on a monthly or bi-weekly basis depending on the severity and change in treatment
Know when to set these claimants up based on clinical and cost knowledge
Complete review of LCNs within 48 business hours of receipt
Notify underwriter and claims auditor of potential risk when first notice received and again as risk changes
Educate non-medical internal and external customers regarding clinical trends, treatments, possible outcomes
Research medical conditions and disease states for appropriate treatment for specific conditions
Utilize reputable clinical resources for research as needed such as NCCN, CDC, Predict Dx
Assess all claimants for potential cost containment opportunities. (approx. 20%)
Collaborate with TPA, case manager, claims auditor, underwriter, vendor to discuss and place appropriate cost containment measures
Maintain timely diary follow-up of all claimants open in POWER. (10%)
Index all documentation received
Co-manage complex medical cases with Transplant/Dialysis coordinator
Provide clinical claim file review for claims auditor as needed. (5%)
Perform appropriate research for each clinical claim file review request
Provide discussion/answer questions for claims auditor as needed
Perform experimental/investigational file reviews for Claims
Review PYCS to assist claim auditor in setting appropriate reserves based on known or anticipated cost
Reviewed all documents indexed into the package for each cost estimator request. (approx. 40% but during busy season-end of August to December approx. 75%)
Perform appropriate research for each cost estimator request
Identify all actual and potential risks for each cost estimator request
Document clinical summary and estimate cost of care for each individual identified as at risk
Provide re-review of additional information for updated cost estimates as needed
Complete requests for cost estimates on new business within 24 business hours of receipt and on renewal business within 48 business hours of receipt
Provide discussion/answer questions for underwriter as needed
Complete Hot Claims reports as needed. This is used to track large claims and any cost containment strategies put in place
Attend monthly Account Management/Sales calls
Qualification
Required
Must be a Registered Nurse (RN) with a current, unrestricted RN license in the state of residence
5+ years of clinical experience
2+ years of experience working in an ER, ICU or Critical Care environment
2+ years of experience working in an insurance or managed care company, or working with a third-party administrator
1+ years of hands on Excel experience
Preferred
Employer Stop Loss experience
Provider Stop Loss, HMO experience
Computer proficiency, specifically solid typing skills and Internet research skills, must have a clear understanding of Microsoft Word and Excel
Demonstrated ability to multitask and remain organized
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Benefits
Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
Company
Optum
Optum is a healthcare company that provides pharmacy services, health care operations, and population health management. It is a sub-organization of UnitedHealth Group.
10001+ employees
H1B Sponsorship
Optum has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (648)
2024 (559)
2023 (620)
2022 (851)
2021 (593)
2020 (438)
Funding
Current Stage
Late StageLeadership Team
Daniel Castillo
Chief Executive Officer, Optum Care Delivery
J
Jay Green
Chief Financial Officer
Recent News
2025-11-29
2025-11-19
2025-11-07
Company data provided by crunchbase