Utilization Management Nurse - Remote

UnitedHealth Group•Sacramento, CA

12h•Remote

About The Position

The Utilization Review Nurse, RN is responsible for providing clinically efficient and effective Inpatient utilization management. Reviews inpatient criteria for acute hospital admissions and concurrent review and or prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all inpatient admission and preauthorization requests from providers that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service or treatment for review with the Medical Director for a decision. Required hours are 8am-5pm in PST or MST to include one weekend day, either Sunday-Thursday or Tuesday-Saturday, after the 3-6 month training period. Training for the first 3-6 months (or potentially longer depending on training progress) will be Monday-Friday 8am-5pm PST before moving to your regular schedule. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Current unrestricted Registered Nurse (RN) license in state of residence
3+ years of clinical nursing experience in acute care hospital or LTAC setting
1+ years of Utilization Management experience in hospital or insurance setting
Experience applying Medicare and/or Medicaid guidelines
Experience with Milliman (MCG) or InterQual guidelines
Experience researching and preparing clinical information for case review with Physician Leadership for patient treatment and care planning
Experience providing accurate and timely documentation of clinical review and supporting rational of decision in care management systems
Experience employing analytical skills necessary for quality case management, utilization review, and quality improvement to meet organizational objectives
Experience using various computer software applications with an intermediate level of competence, including Microsoft Word and Excel
Ability to work Monday-Friday 8am-5pm in Pacific Time Zone or Mountain Time Zone to include one weekend day, either Sunday-Thursday or Tuesday-Saturday, after the 3-6 month training period. Training for the first 3-6 months (or potentially longer depending on training progress) will be Monday-Friday 8am-5pm PST before moving to your regular schedule

Nice To Haves

Inpatient Utilization Management experience
Utilization Management experience for insurance or managed care organization
Prior Authorization experience
Primary residence in Pacific Time Zone or Mountain Time Zone

Responsibilities

Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes
Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
Documents clinical reviews in care management system. Provide accurate and timely documentation and supporting rational of decision in care management system
Utilizes care management system and resources to track and analyze utilization, variances and trends, patient outcomes and quality indicators
Research and prepares clinical information for case review with Physician Leadership for patient treatment and care planning
Utilizes knowledge of resources available in the health care system to assist the physician and patient effectively
Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member’s needs along the continuum of care
Successfully completes the Interrater Reliability Testing to ensure consistency of review and application of criteria
Meets timeliness standards for decision, notification, and prior authorization activities
Serves as an advocate for all providers and their patients
Demonstrates a positive attitude and respect for self and others and responds in a courteous manner to all customers, internal and external
Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding Optum business
Performs other duties as required or requested in a positive and helpful manner to enable the department to achieve its goals