Manager of Utilization Management - Washington D.C. - Optum

UnitedHealth Group•Washington, DC

2d•$91,700 - $163,700•Hybrid

About The Position

Optum Home & Community Care, part of the Optum family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs — helping patients access and navigate care anytime and anywhere. As a team member of our Optum Care at Home team, together in an interdisciplinary care environment, we help patients navigate the health care system and connect them to key support services. This preventive care can help patients stay well at home. This life-changing work adds a layer of support to improve access to care. We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together. The Dual Special Needs Plan (DSNP) Optum at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. The DSNP program combines Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the Optum clinician, the member’s Primary Care Provider and other providers, and other professionals. Optum providers serve people in their own homes through annual evaluations, ongoing visits for higher risk members, care coordination during transitions from the hospital or nursing home and ongoing care management. The RN Utilization Manager is accountable for HCBS Review Case Managers who perform evaluation of Home and Community Based Services (HCBS) of members in the Optum at Home Long Term Services and Support program. In collaboration with Optum Medical Director, this position is responsible for HCBS Review outcomes, business operation targets and overseeing the work activities of HCBS Review team.

Requirements

Current unrestricted RN license in Washington DC
3+ years of related Utilization Management experience with focus on medical necessity reviews, compliance adherence, data analysis and managing and developing a team, preferably with specific Medicaid experience
Proven experience in developing and sustaining internal and external client relationships with healthcare professionals
Proficient computer skills, including the ability to document medical information with written and electronic medical records
Valid Driver’s License and Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area
Willing or ability to up to 25-50%25 travel within Washington DC

Nice To Haves

BSN
Interqual or MCG certification or experience
Certified Case Manager Certification (CCM)
Knowledge of Medicare Dual (DSNP) and Medicaid environment
Knowledge of Long-Term Services and Support (LTSS) and Home and Community Based Services (HCBS)
Knowledge of managing complex medical conditions
Proven solid business acumen including analysis and business planning experience
Proven solid organizational skills and multitasking abilities will be keys to success
Proven solid clinical critical thinking skills
Proven excellent communication skills and demonstrated ability to foster a culture of clinical excellence and build collaborative relationships
Must live within 50 miles for Washington DC

Responsibilities

Set team direction, resolve problems, and provide guidance to members of own team
Lead, supervise, and develop members of the DSNP clinical team utilizing the weekly Grand Rounds for teaching and training activities related to HCBS review and care planning for members
Oversee work activities of other supervisors and staff with formal monthly HCBS Review manager meetings and participation in All Staff Training Sessions regarding HCBS review topics
Adapt departmental plans and priorities to address business and operational challenges
Responsible for policies and procedures for the authorization, oversight and monitoring of member’s long-term services and support
Influence and/or provide input to forecasting and planning activities
Ensures the team meets established performance metrics and performance guarantees through Clinical Utilization Excellence rounds with case presentation to identify services and resources that align with members’ care needs and development of care plan and assist with Transition of Care discussions
Ensure effective orientation and development for Clinical Staff in collaboration with New Hire Orientation Training team covering HCBS review work
Utilize Complex Population Management performance tools that hold the clinical team accountable for market metrics and performance standards including use of HCBS review form and Time to Task Tool within Pathway application
Promote individual development by providing learning and growth opportunities to clinical staff
Communicate needs and issues addressed by clinical staff to local market and corporate leadership as appropriate
Participate in site specific strategic planning activities
Develop solutions to problems or barriers by partnering with key stakeholders including serving as liaison with Health Plan and DC Providers with Home & Community Based Services regarding utilization of long-term support and services resources
Provide clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)
Serve as a role model to internal and external partners
Oversee implementation and adoption of clinical and quality initiatives
Use knowledge of the business and financial goals to determine and communicate clinical priorities
Partner with staff to achieve business goals
Monitor and hold clinical team accountable for Model of Care documentation
Actively engage, coach and drive clinical staff in implementing activities to grow new membership