Utilization Management Nurse RN

UnitedHealth Group • Houston, TX

385d

About The Position

The Utilization Management Nurse RN at UnitedHealth Group is responsible for providing efficient and effective risk management according to specific benefit plans for PreferredOne products. This role involves conducting utilization reviews to ensure medical necessity and appropriateness of care, while also collaborating with healthcare providers and internal teams to enhance patient outcomes and manage costs effectively.

Requirements

• Active, Unrestricted RN License
• Compact State License
• 5+ years of clinical experience
• 2+ years of Utilization Management experience
• Excellent communication skills for effective collaboration
• Strong interpersonal skills in a high-activity environment
• Ability to multi-task and prioritize in a fast-paced setting
• Proficient in Microsoft Office Tools (Excel, Word, Outlook)
• Designated distraction-free workplace with internet access

Nice To Haves

• Experience in Case Management Collaboration
• Medical experience in NICU, Transplants, Rehabilitation, Surgical, Home Healthcare and Appeals
• Knowledge of insurance industry including benefit plans and mandates

Responsibilities

• Utilize Preferred One medical criteria and regulatory guidelines to perform medical necessity reviews.
• Conduct inpatient and outpatient pre-admission and concurrent reviews based on medical necessity and appropriateness of treatment.
• Document utilization review strategies clearly and concisely online.
• Apply benefit language accurately to each review situation.
• Identify high-risk cases for complex discharge planning and make appropriate referrals.
• Perform utilization reviews for complex medical conditions such as Transplants and NICU inpatient cases.
• Assist with Transition of Care and Extended Hour Nursing reviews.
• Conduct Pre-Service and Post-Service Appeal reviews.
• Refer cases not meeting medical necessity criteria to a medical reviewer for determination.
• Identify cases with high case management potential before or at admission.
• Transfer cases for Chronic Illness Management or Complex Case Management as appropriate.
• Collaborate with PreferredOne providers to obtain necessary information.
• Contact management to recommend flexing or extending benefits to avoid costly services.
• Assist in developing policies and procedures to improve risk management processes.
• Work with other staff to identify and solve issues through provider education and contracting.
• Review claims and data to assess patients for high case management potential.
• Monitor case information for quality and patient safety issues.

Benefits

• Comprehensive benefits package
• Career development opportunities
• Diversity and inclusion culture

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: No Education Listed