Secondary Review Nurse - Indiana

UnitedHealth Group•Indianapolis, IN

1d•Remote

About The Position

The Secondary Review Nurse plays a critical role in evaluating clinical requests for Home and Community-Based Services (HCBS). This position ensures that care provided is medically necessary, cost-effective, and tailored to the individual needs of each member, while remaining compliant with state regulations. If you reside within the state of Indiana, you will enjoy the flexibility to work remotely as you take on some tough challenges.

Requirements

Current, unrestricted RN license for Indiana
3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care or case management and the ability to quickly identify needs and issues
2+ years of experience with completing functional assessments for LTSS services
2+ years of Medicaid, Medicare, or Managed Care experience and with Long-Term Services and Supports
Intermediate level of knowledge of LTSS experience determining eligibility and appropriate allocation of services
Intermediate level of computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications

Nice To Haves

Pre-authorization experience
Utilization Management experience
Case Management experience
Knowledge of state and federal guidelines
Home health or hospice
Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action

Responsibilities

Participate in secondary reviews for HCBS services and Medicaid services
Review and process prior authorization requests for LTSS and HCBS services
Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services
Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the members’ service plan
Monitor utilization patterns and identify opportunities for improved care coordination and cost containment
Document all clinical decisions and communications in accordance with regulatory and organizational standards
Support quality improvement initiatives and participate in developing education and training for staff
Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed
Stay current with established guidelines and regulatory requirements