Utilization Management Nurse RN

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Support and promote Optum and Bassett Healthcare Network goals and mission
• Onsite presence as needed to build relationships across Optum and the Bassett Healthcare Network
• Collaborate with peers in Medical Management, Case Management, RCM, Compliance, and Quality Management to assure continuity of communication and care
• Work in Epic and Case Advisor as well as Tiger Connect/phone providers
• Maintain proficient knowledge of the database and/or programs utilized by Optum and Bassett Healthcare Network
• Will promptly report any issues with the database and/or programs
• Review patient records daily to assess appropriateness of admission and ongoing medical care
• Apply clinical criteria and guidelines to ensure appropriateness of admission based on the use of relevant MCG criteria and Medicare regulations and guidelines as appropriate
• Refer to Physician Advisors at Optum and/or at Bassett Healthcare Network when cases do not meet clinical criteria guidelines and require second level review as appropriate
• Monitor patient status in Epic and in Case Advisor, escalating patient records that require a discussion on status
• Addresses Code 44 cases with Onsite Physician Advisor, Attending Physician and Case Manager timely
• Work with the Utilization Management Nurse Manager to identify patient utilization trends to assist the Bassett Healthcare Network to better assess their clinical care needs
• Assist in resolving conflicts or issues with patient statuses and have a clear understanding of when a situation needs to be escalated to a supervisor and/or management for timely resolution
• Secondary Functions
  • Work in a manner that is not disruptive to peers, supervisors and/or subordinates
  • Maintain regular and acceptable attendance level as determined by the employer
  • Maintain availability and willingness to work such days and hours the employer determines are necessary or desirable to meet its business needs
  • Assist and support the Director and Utilization Management Nurse Manager to maintain consistency and accuracy of the workflow processes of the team
  • Maintain strict patient confidentiality
  • Professional demeanor and the ability to work effectively within a team and/or independently
  • Flexible with the ability to shift priorities when required
  • Ability to navigate electronic medical records
  • Other duties as requested
• Case Processing
  • Will accurately and efficiently review clinical data from the patient records focusing on key elements and obtain additional information as needed for case review completion
  • Will accurately complete cases according to guidance provided
  • Will verify the accuracy and thoroughness prior to completing reviews
  • Maintain or exceed quality expectations
  • Will participate in productivity and quality review meetings upon request from their direct supervisor
  • Impart confidential information appropriately per HIPAA regulations and company requirements and will follow the HIPAA policies
  • Will impart confidential information appropriately per HIPAA regulations and company requirements
  • Will identify instances of potential HIPAA violations and notify the appropriate staff of company policies and procedures
  • Will maintain a secure working environment following Optum and Bassett Healthcare Network security policies and procedures
• Perform other related duties, tasks, and processes as required by Nursing leadership
• Interdepartmental collaboration
  • Will work in collaboration with other departments
  • Will assist with identification and correction of inaccurate and incomplete information
  • Will submit potential HIPAA issues per policy
  • Will assist other departments as the business needs dictate
  • Will provide ongoing support to other department team members
• Education, Projects and Meetings
  • Will attend company, team, and individual meetings as directed
  • Will remain up to date on competencies
  • Will complete E- Learning courses per policy
  • Will complete MCG trainings as directed
  • Will participate in additional training and/or projects under the direction of Nursing leadership

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Associate's Degree in Nursing (or higher)
• Current Registered Nurse licensure and obtain New York licensure
• 5+ years of experience in med/surg OR 3+ years in critical care experience
• 2+ years of Utilization Management experience
• Intermediate level of proficiency with strong typing skills in Microsoft applications specifically Microsoft Word and Excel

Preferred Qualifications:

• Epic/EMR experience
• Pre-authorization experience
• Strong knowledge of clinical requirements for inpatient medical necessity hospitalizations
• Case Management experience
• Working knowledge of InterQual and/or MCG Guidelines with the ability to apply criteria consistently and accurately
• Certified Case Manager (CCM)

Soft Skills:

• Demonstrates organization
• Professional attitude and team player, with ability to work independently
• Knowledge of insurance payer processes
• Ability to learn and understand various clinical software applications
• Strong written and verbal communication skills - able to convey key concepts clearly and succinctly
• Experience in fostering collegial relationships and partnerships amongst colleagues
• Demonstrates collaborative skills and ability to interact with people of different backgrounds and organizational levels, including clients
• Self-motivated and able to function in a fast-paced work environment
• Demonstrates the ability to stay focused on the detail
• Ability to use sound judgment, deductive reasoning, and problem-solving abilities with the ability to multi-task and prioritize work
• Ability to adapt to changes in priorities and can absorb changes in the work volume
• Meets and maintains quality and productivity standards

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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

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