Utilization Management RN - Remote - Remote Eligible

Prior Authorization RN

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.

The Prior Authorization RN ensures that prior authorization requests from patients and providers are completed in a timely fashion to meet the contractual and regulatory requirements while acting within the scope of the Board of Nursing of the State of California. The Prior Authorization RN will promote the quality and cost effectiveness of medical care provided to patients by applying clinical acumen and using appropriate nationally recognized guidelines, criteria, and evidence based standards. Also assists UM management and Compliance team in preparation for audits and other regulatory activities as needed.

If you are located in CA, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Screening and reviewing prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service and care and discussing with Medical Directors
• Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources and community resources
• Prospective review to determine appropriateness of denial, possible alternative treatment, and draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language
• Coordinate out-of-network and out-of-area cases with member, health plans and Case Management team
• Review's patient referrals within the specified care management policy timeframe (Type and Timeline Policy)
• Develop and maintain effective working relationships, with physicians and office staff. Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through utilization of appropriate reports such as Health Plan Eligibility and Benefits and Division of Responsibility (DOR)
• Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients, and families

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:

• Active, unrestricted RN license in the state of California
• 2+ years of clinical experience in an acute or ambulatory patient care setting including 1+ years in a managed care environment such as a medical group, independent physician association, or health plan
• Willing or ability to work 8-5PM PST

Preferred Qualifications:

• 3+ years of experience working as a RN
• 2+ years of Utilization Management experience
• Experience in an HMO or experience in a Managed Care setting

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 hourly pay for this role will range from $28.27 to $50.48 per hour 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 under applicable law 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, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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