UM Nurse- Non SRT Remote in Indiana

UnitedHealth Group•Indianapolis, IN

4d•Hybrid

About The Position

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The UM Nurse, Non SRT 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. In addition, must assist with oversight of prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, care coordination and other clinical and medical management programs. This is a key position for the contract – hybrid (office/telecommute) required. If you reside within the state of Indiana, you will enjoy the flexibility to work remotely as you take on some tough challenges. Willingness to travel 10-15%25 of the time within Indiana.

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 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
Access to reliable transportation and & valid US driver's license

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

Monitors activities of national UM staff regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care and other clinical and medical management programs
Aids, approves and intervenes as needed to determine medical necessity, appropriateness and extended length-of-stay decisions
Participates in State- or plan-required audits and complies with all reporting requirements by area of responsibility
Oversees reporting and monitors potential high-cost cases, readmissions, UM statistics to include admits per thousand, bed days per thousand, length-of-stay and readmissions per thousand within 30 days of discharge
Participate in secondary reviews for Medicaid services
Review and process prior authorization requests for LTSS and Medicaid 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 member’s 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