RN Clinical Review Coordinator Florida

For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Schedule is 4 10-hour shifts, Saturdays required. Must have a Florida State RN License and reside in Florida 

Primary Responsibilities:

• Research member benefits and eligibility
• Completes all assigned cases within required timeframes (TAT)
• Processes and documents all case activities per SOPs and DES
• Prepares and documents clinical case review and assigns to Medical Director for Medical Director (LTAC, AIR and SNF) decision
• Approves SNF cases where RN’s clinical review indicates that member’s condition meets clinical criteria
• Approves SNF cases where an LPN’s clinical review indicates that member’s condition meets clinical criteria
• Communicates and documents Medical Director determinations to providers and members
• Maintains communications with providers for continuity of care and completion of ALOC requests
• Prepares case information for assignment to National Letter Team
• Submits requested Contract Exceptions for SNF cases
• Educates providers, members and internal staff on guidelines, member benefits, alternate levels of care available
• Acts as a clinical resource to LPNs, PTs, and Non-Clinical staff
• Collaborates with other internal stakeholder’s/departments for member’s appropriate level of care: Medical Director, Optum/United Nursing Home members, Appeals and Grievances, National Letter team, and Intake/CDU
• Performs self-audits to assure compliance with SOP DES
• Works within HSR, InterQual, and multiple SharePoint sites
• Participates in compliance meetings, process improvement planning
• Reports individual case concerns to manager, Medical Director as needed
• Triage cases received from IPC
• Assign cases to Facility ICM or other work groups

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 RN license in state of Florida
• 5+ years clinical experience
• 3+ years of experience in Case Management, UM preferred
• 1+ years working in managed care or in the insurance industry
• Experience with Medicare and/or Medicaid
• Proficient in software applications that include, but are not limited to, Microsoft Word, Excel, PowerPoint, OneNote, Teams and Outlook
• Proven ability to evaluate medical records with attention to detail
• Proven solid organizational skills, self-motivated and ability to interact with staff at all levels
• Live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
• Located in Florida 
• Ability to work 4-10’s if needed which would include  Saturday Shift – i.e. Wed-Sat, No Sundays
• Have a dedicated work area established that is separated from other living areas and provides information privacy

Preferred Qualifications:

• Case management certification and/or experience
• Experience in chart review
• Experience in acute long-term care, acute rehabilitation, or skilled nursing facilities
• Experience in utilization review for an insurance company or in a managed care environment
• Experience with InterQual or MCG evidence based criteria

Soft Skills:

• Solid computer skills
• Solid communication skills, written and verbal
• Ability to build and maintain relationships will be essential

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

The hourly range for this role is $34.42 to $67.60 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.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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: OptumCare 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.

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