RN, Utilization Management Nurse – Remote

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.  

Responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making as it relates to the application of criteria and defined levels of hierarchy and composition of regulatory requirements. 

If you have an active RN License in CA and able to work Pacific Standard Time (PST), you will have the flexibility to work remotely* as you take on some tough challenges. 

Primary Responsibilities:

• Performs all functions of an UM Nurse
• Consistently exhibits behavior and communication skills that demonstrate OPTUM’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer
• Implements current policies and procedures, standardization requirements set by the Utilization Management and by the UM Compliance department
• Implements and maintains regulatory turnaround times
• Responsible for implementing accuracy and accountability of the information provided when prepping referral requests for medical necessity and redirection within primary network with CMS and health plan appropriate guidelines
• Reviews patient referrals within the specified utilization management policy and regulatory compliance timeframes, manages production and ensures services to our providers and patients in a timely manner (Type and Timeline Policy)
• Assures that they utilize Standard Documentation when prepping referrals for processing
• Communicates authorization or denial of services to appropriate parties  Communication may include patient (or agent), referring physician, and Optum claims as necessary
• Demonstrates a thorough understanding of the cost consequences resulting from utilization management decisions through utilization of appropriate reports such as Health Plan Eligibility and
• Benefits, Division of Responsibility (DOFR)
• Ensures appropriate utilization of medical facilities and services within the parameters of the patients’ benefits and/or CMC decisions
• Maintains effective communication with the health plans, physicians, hospitals, patients and families
• Meets or exceeds all productivity standards set by your manager
• Maintains accurate and complete documentation of care rendered including POS, CPT Code, ICD-10, referral type, date, etc
• Completes and passes IRR (Interrater Reliability) at prescribed intervals per Management
• Attends all educational webinars and/or views on the SharePoint and takes knowledge checks as per Management and UM Education direction
• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Performs additional 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:

• Graduation from an accredited school of Nursing
• Current California RN license

Preferred Qualifications:

• 2+ years of Prior Authorization UM experience

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

The hourly range for this role is $28.61 to $56.06 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.