Utilization Management Specialist – Remote in MN or WI

Opportunities at Optum, in strategic partnership with Allina Health. As an Optum employee, you will provide support to the Allina Health account. 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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

 

The Utilization Management Specialist collaborates with the care team to confirm the level of care and authorization for services. Reviews medical records and prepares clinical reviews for medical necessity and authorization. Is also responsible for facilitating the denial and appeal process.    

 

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

 

Primary Responsibilities:

• Ensures the appropriate mental health/behavioral health services are medically necessary and at the appropriate level of care per health plan benefits and patient care needs
• Assesses clinical data from medical records to assure appropriateness of patient’s admission
• Utilizes screening criteria to determine patient status
• Assures the medical record has the proper physician order and/or clinical documentation
• Monitors continued stay to identify potential issues and communicates results and opportunities to Allina Health System Behavioral Health Department staff, leadership, physicians and case manager
• Evaluates potential denials or payment issues and initiates communication with physician or clinician regarding next steps
• Prepares and facilitates appeals for denied claims
• Facilitates peer to peer requests between admitting, attending physician, and the payer physician
• 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 Social Worker – Minnesota Board of Social Work, or Licensed Marriage and Family Therapist- Minnesota Board of Family Therapy, or Licensed Professional Clinical Counselor- Minnesota Board of Behavioral Health and Therapy, or Registered Nurse- Minnesota Board of Nursing. All licensure in good standing, unrestricted
• 2+ years of direct care experience in an acute hospital behavioral health/mental health setting, or free-standing treatment center
• 1+ years of experience using diagnostic and statistical manual (DSM) documentation standards

 

Preferred Qualifications:

• Licensed Independent Clinical Social Worker (LICSW) in good standing/unrestricted
• 2+ years of case management experience, and/or Utilization Management experience within an acute hospital system or insurance/managed care organization.  
• Epic experience

 

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

 

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.

 

 

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

 

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