Utilization Management Nurse RN

UnitedHealth Group•Albany, NY

20h•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. You’ll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.

Requirements

Associate’s Degree in Nursing (or higher)
Current Registered Nurse licensure and obtain New York licensure
5+ years of experience in med/surg OR 3+ years in critical care experience
2+ years of Utilization Management experience
Intermediate level of proficiency with strong typing skills in Microsoft applications specifically Microsoft Word and Excel
Demonstrates organization
Professional attitude and team player, with ability to work independently
Knowledge of insurance payer processes
Ability to learn and understand various clinical software applications
Strong written and verbal communication skills - able to convey key concepts clearly and succinctly
Experience in fostering collegial relationships and partnerships amongst colleagues
Demonstrates collaborative skills and ability to interact with people of different backgrounds and organizational levels, including clients
Self-motivated and able to function in a fast-paced work environment
Demonstrates the ability to stay focused on the detail
Ability to use sound judgment, deductive reasoning, and problem-solving abilities with the ability to multi-task and prioritize work
Ability to adapt to changes in priorities and can absorb changes in the work volume
Meets and maintains quality and productivity standards
All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Nice To Haves

Epic/EMR experience
Pre-authorization experience
Strong knowledge of clinical requirements for inpatient medical necessity hospitalizations
Case Management experience
Working knowledge of InterQual® and/or MCG Guidelines® with the ability to apply criteria consistently and accurately
Certified Case Manager (CCM)

Responsibilities

Support and promote Optum and Bassett Healthcare Network goals and mission
Onsite presence as needed to build relationships across Optum and the Bassett Healthcare Network
Collaborate with peers in Medical Management, Case Management, RCM, Compliance, and Quality Management to assure continuity of communication and care
Work in Epic and Case Advisor as well as Tiger Connect/phone providers
Maintain proficient knowledge of the database and/or programs utilized by Optum and Bassett Healthcare Network
Will promptly report any issues with the database and/or programs
Review patient records daily to assess appropriateness of admission and ongoing medical care
Apply clinical criteria and guidelines to ensure appropriateness of admission based on the use of relevant MCG® criteria and Medicare regulations and guidelines as appropriate
Refer to Physician Advisors at Optum and/or at Bassett Healthcare Network when cases do not meet clinical criteria guidelines and require second level review as appropriate
Monitor patient status in Epic and in Case Advisor, escalating patient records that require a discussion on status
Addresses Code 44 cases with Onsite Physician Advisor, Attending Physician and Case Manager timely
Work with the Utilization Management Nurse Manager to identify patient utilization trends to assist the Bassett Healthcare Network to better assess their clinical care needs
Assist in resolving conflicts or issues with patient statuses and have a clear understanding of when a situation needs to be escalated to a supervisor and/or management for timely resolution
Work in a manner that is not disruptive to peers, supervisors and/or subordinates
Maintain regular and acceptable attendance level as determined by the employer
Maintain availability and willingness to work such days and hours the employer determines are necessary or desirable to meet its business needs
Assist and support the Director and Utilization Management Nurse Manager to maintain consistency and accuracy of the workflow processes of the team
Maintain strict patient confidentiality
Professional demeanor and the ability to work effectively within a team and/or independently
Flexible with the ability to shift priorities when required
Ability to navigate electronic medical records
Other duties as requested
Will accurately and efficiently review clinical data from the patient records focusing on key elements and obtain additional information as needed for case review completion
Will accurately complete cases according to guidance provided
Will verify the accuracy and thoroughness prior to completing reviews
Maintain or exceed quality expectations
Will participate in productivity and quality review meetings upon request from their direct supervisor
Impart confidential information appropriately per HIPAA regulations and company requirements and will follow the HIPAA policies
Will identify instances of potential HIPAA violations and notify the appropriate staff of company policies and procedures
Will maintain a secure working environment following Optum and Bassett Healthcare Network security policies and procedures
Perform other related duties, tasks, and processes as required by Nursing leadership
Will work in collaboration with other departments
Will assist with identification and correction of inaccurate and incomplete information
Will submit potential HIPAA issues per policy
Will assist other departments as the business needs dictate
Will provide ongoing support to other department team members
Will attend company, team, and individual meetings as directed
Will remain up to date on competencies
Will complete E- Learning courses per policy
Will complete MCG® trainings as directed
Will participate in additional training and/or projects under the direction of Nursing leadership