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.

The Utilization Management Nurse RN, utilizing critical thinking skills and their clinical background, is responsible for reviewing clinical information from patient electronic medical records requested by our clients. They will coordinate key clinical findings, will run the clinical through agreed upon screening tool and will propose an initial case recommendation based on criteria outcome, supporting the clinical stay and/or supporting a case. The nurse will also handle payor communications as appropriate.

The nurse will check the accuracy and thoroughness of their work prior to sending the case to our clients. The nurse will maintain quality and productivity expectations. The nurse will provide frontline customer service to clients and work in collaboration with other departments to ensure continuity of client care and satisfaction.

Schedule: Flexible in what they can cover - Operation is 8 AM - 8 PM - Every other weekend and rotating holidays.

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

Primary Responsibilities:

• The First Level Review Nurse will accurately and efficiently review case details from patient records focusing on key elements according to process and follow the agreed upon screening tools. The nurse will complete their case within the time expectations and provide high quality reviews. The First Level Review Nurse will perform their job functions, adhering to Optum Physician Advisor Solutions policies and procedures, which include but are not limited to the following
• Arrive to work on time and comply with time off expectations
  
  
  
  • Will adhere to company policies and procedures regarding scheduled arrival and breaktimes as well as Holiday commitments and time off expectations
  • Will maintain an accurate account of time off in Verint and HR Direct as per policy guidelines
  • Will submit time off requests, temporary schedule changes, schedule adjustments, and/or report any scheduling discrepancies/errors per policy and procedure guidelines
  
  
  
  

• The First Level Review Nurse will work in OPAS clinical database/clinical data entry or directly in the client's database




• Will enter clinical information into the company's/client's database as defined by the company policies and procedures
• Will maintain proficient knowledge of the database and/or programs utilized by the First Level Team and other departments as needed
• Will promptly report any issues with the database and/or programs utilized by the First Level Team to IT and to the supervisory staff as needed




• Review the inpatient clinical chart of patients in their assigned hospitals daily to assess the appropriateness of admission and ongoing medical care
• Apply clinical criteria and guidelines to ensure appropriate admission based on the use of relevant InterQual or MCG criteria and Medicare regulations and guidelines as appropriate
• Refer to Physician Advisors at Optum when cases do not meet clinical criteria guidelines and require second level review as appropriate
• Communicate clearly and effectively to client/provider/payer and internal Optum staff pertinent patient information to facilitate timely processing of cases and adhere to departmental turnaround times
• Work with Optum employees to identify patient utilization trends to assist clients to better assess their clinical care needs
• Complete data entry of admissions in the medical management systems, Review Manager or Indicia, daily including accurate patient demographics, working diagnosis, and clinical information
• Assist in resolving conflicts or issues between clients and Optum and have a clear understanding of when a situation needs to be escalated to a supervisor and/or management for timely resolution
• Responsible for maintaining accurate and complete files for each client hospital
• Willingness to cross train to other RN departments to assist when needed
• Secondary Functions




• Work in a manner that is not disruptive to peers, supervisors and/or subordinates
• Maintain regular and acceptable attendance at such level as is determined at the employer's sole discretion
• Maintain availability and willingness to work such days and hours as the employer determines are necessary or desirable to meet business needs
• Assist and support the Director and Manager of First Level Review team to maintain consistency and accuracy of the workflow process of the team
• Maintain strict patient confidentiality
• Professional demeanor and the ability to work effectively within a team or independently
• Flexible with the ability to shift priorities when required
• Ability to navigate electronic medical records
• Payor communication and handling of requests as appropriate
• 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 complete cases according to the guidance provided accurately
• Will verify the accuracy and thoroughness prior to submitting the cases to our clients
• Will complete the minimum case per hour/per day productivity requirements while maintaining quality expectations
• Process reviews as required by assuring timeliness
• Maintain or exceed quality expectations




• Will participate in productivity and quality review meetings upon request from their direct supervisor
• Will report any issues which may impact productivity or quality to their direct supervisor (including IT issues, ISP issues etc.)
• Impart confidential information appropriately per HIPAA regulations and company requirements and will follow the HIPAA policies
• Will appropriately communicates with payors
• Will impart confidential information appropriately per HIPAA regulations and company requirements
• Will identify instances of potential HIPPA violations and notify the appropriate staff per company policies and procedures
• Will maintain a secure working environment following the company's security policies and procedures






• Performs other related duties, tasks, and processes as required by the Nursing leadership
• Interdepartmental collaboration




• Will work in collaboration with other departments to ensure minimum case data is provided to complete reviews as defined by OPAS processes
• Will assist with identification and correction of inaccurate and incomplete information
• Will submit potential HIPPA issues per OPAS process
• Will assist other departments as the business needs dictate
• Will provide ongoing support to other department team members assisting in the NCC and CDEN queues




• Education, Projects, and Meetings




• Will attend company, team, and individual meetings as directed
• Will complete E- Learning courses per policy
• Will complete MCG and InterQual training as directed
• Will participate in additional training and/or projects under the direction of the Nursing leadership

What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
• More information can be downloaded at: http://uhg.hr/uhgbenefits

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:

• High School Diploma/GED (or higher)
• Active Registered Nurse (RN) licensure
• 3+ years of med/surg and/or critical care experience

Preferred Qualifications:

• 2+ years of case management and/or concurrent/utilization review experience
• Current working knowledge of InterQual or MCG Guidelines
• Typing proficiency of at least 45 wpm
• Intermediate level proficiency utilizing Microsoft applications

*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 $58,800 to $105,000 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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