Bariatric RN Case Manager

UnitedHealth Group • Aurora, IL

196d • $59,500 - $116,600 • Remote

About The Position

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 Bariatric Prior Authorization RN Case Manager is responsible for clinical operations and medical management activities across the continuum of care for members seeking Bariatric surgery. This will include performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness services following evaluation of medical guidelines and benefit determination. Ready for a new path? today! The required schedule is Monday through Friday: 4 days 8:00am to 5:00pm and 1 day 10:30am to 7:00pm. You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

• Current, unrestricted RN license in your state of residence
• Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses
• 3+ years of experience in a hospital setting managing medical/surgical, ICU, bariatric patients, or complex case management
• Intermediate level of proficiency with Microsoft Word, including the ability to navigate a Windows environment
• Ability to work until 8:00pm at least one night per week
• Access to high-speed internet from home (Broadband cable, DSL or Fiber)
• Designated workspace from home

Nice To Haves

• Bachelor's Degree
• Certified Case Manager (CCM)
• Compact/Multi-State RN license
• Bariatric experience as the main focus of your job
• Prior Authorization/Utilization Management/Review experience
• Post-surgical experience
• Patient education experience
• Discharge planning experience
• Case Management/Care Coordination experience
• Managed care background
• Knowledge of Milliman (MCG) or InterQual criteria
• Reside in a compact license state with a compact license

Responsibilities

• Makes outbound calls to assess members' current health status
• Case Manages members in the pre-operative and post-operative phases of Bariatric surgery to ensure a positive outcome
• Identifies gaps or barriers in treatment plans and coordinate ongoing care with providers
• Provides patient education to assist with self-management and healthy lifestyle changes
• Stays connected with members to help them stay on the right track regarding diet and weight loss goals
• Documents and tracks progress from initial assessment through post-operative care
• Interacts with Medical Directors on challenging cases
• Makes ‘post operation' calls to ensure that discharged member receives the necessary services and resources
• Prioritizes cases based on appropriate criteria (e.g., date of service, urgent, expedited)
• Ensures compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
• Reviews/interprets clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
• Identifies missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
• Makes determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
• Reviews care coordinator assessments and clinical notes, as appropriate
• Identifies relevant information needed to make medical or clinical determinations
• Identifies and utilizes medically accepted resources and systems to conduct clinical research (e.g., clinical notes, client criteria)

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree