Acute Utilization Review RN

Caring. Connecting. Growing Together.

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.

Positions in this function are responsible for timely, accurate medical review, determining if requests for services to be provided to The Group patients meet criteria for coverage based upon medical policies, guidelines, and health plan criteria. Responsible for review of inpatient length of stay for compliance with medical policies, guidelines, and health plan criteria. Based on criteria may refer cases to Medical Director Care Management for further review. Ensures compliance to contractual and service standards as identified by relevant health insurance plans and The Group.

This is performed under the direct supervision of the Medical Director, Care Management. Adheres to policies, procedures and regulations to ensure compliance and patient safety. Participation in Compliance and other important training is a condition of employment.

Primary Responsibilities:

• Provides timely, accurate review of precertification and prior authorization requests, for compliance with applicable medical policies and health plan benefits
• Provides concurrent medical review of inpatient length of stays to ensure compliance with applicable medical policies and health plan benefits
• Providing both outpatient and inpatient medical management review as needed, to ensure that patient healthcare requirements and organizational goals are met in a reasonable and medically appropriate manner
• Ensure communication regarding medical reviews are provided to relevant patients and Providers in a timely manner, and in compliance with contractual agreements
• Ensures compliance with HIPAA and other applicable company policies and procedures as well as regulatory requirements
• Identify and address opportunities for quality improvement in all aspects of serving our customers. Assist in planning and implementation of systems changes and procedures to achieve overall organizational objectives
• Maintain effective communication with management regarding development within areas of assigned responsibilities and performs special projects as required
• MCG certification within one year of hire
• Performs other duties as assigned

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Licensed in state of residency
• 3+ years of job-related experience in a healthcare environment
• Working knowledge of HMO’s, PPO’s, Medicare, Medicaid, and insurance plans
• Knowledge of CPT4/ICD 9 & 10/HCPCS codes
• PC proficient
• Demonstrated ability to communicate and interact professionally with co-workers, management patients, and Providers
• Demonstrated ability to counsel and/or consult
• Must pass a nationwide criminal history screen through the Caregivers Criminal History Screening Program
• Weekend availability

Preferred Qualifications:

• Bachelor’s degree in Nursing
• Utilization Review or Case Management Certificate
• 2+ years of experience providing case management and/or utilization review functions within health plan or integrated system

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. UnitedHealth Group is an Equal Employment Opportunity employer and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.