Utilization Management , TN – Remote in WA

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.  

 

The Utilization Management, RN will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for complex and/or critical issues. This position will communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding; and will provide summary clinical and ancillary information to the Health Plan Medical Director for review and decision making, including state fair hearings.

 

If you have a WA RN license (or covered under RN compact licensure), you will have the flexibility to work remotely* as you take on some tough challenges.

 

Primary Responsibilities: 

• Functional role is responsible for utilization management of administrative and IBSS determinations, oversight on outpatient service requests from a reporting perspective and understanding the criteria for inpatient reviews, including concurrent inpatient reviews
• Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in each situation
• Determines medical appropriateness using medical guidelines and benefit determination
• Solves complex problems and develops innovative solutions
• Ability to support and facilitate biweekly meetings for Complex/High Risk members in conjunction with leadership and Health Services staff
• Provides explanations and information to others on the most complex issues
• Leverage appropriate clinical terminology when communicating with physicians and other medical professionals
• Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action
• Apply professional judgment, take initiative to follow up, and manage conversations to make sound conclusions/recommendations regarding LTSS patient care or coverage
• Apply information about patient condition and benefit applicability/limitations of coverage to make recommendations
• Generally, work is self-directed and not prescribed
• Works with less structured, more complex issues
• Works with minimal guidance; seeks guidance on only the most complex tasks
• Coaches, provides feedback, and guides others
• Acts as a resource for others with less experience
• Anticipates customer needs and proactively develops solutions to meet them
• Prepares reports as directed

 

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 independent WA RN license
• 3+ years of clinical experience
• 1+ years of Utilization Management experience
• 1+ years of experience with MS Office, including Word, Excel, and Outlook
• Willing or ability to adhere to a Monday – Friday 8a – 5p MST work schedule

 

Preferred Qualification:

• InterQual Certified and/or Milliman (MCG) Certified
• Reside in the state of Washington

 

*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 $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. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.   

 

 

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.