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.
The shift is Monday through Friday 8am-5pm in Pacific or Mountain Time Zone. Weekend rotation is required.
If you are located in PST or MST, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary 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
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: - Current unrestricted Registered Nurse (RN) license in state of residence
- Ability to obtain Registered Nurse license in the state of California within 90 days of hire
- 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
- Primary residence in Pacific or Mountain Time Zones and required to work Weekend and Holiday hours
Preferred Qualifications:- Inpatient Utilization Management experience
- Utilization Management experience for insurance or managed care organization
- Prior Authorization experience
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.
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). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $29.00 to $52.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
