Utilization Management Nurse – Colorado – Remote

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. 

As part of a utilization management team who will manage complex members, the Utilization Management Clinical Coordinator, Substance Use and Behavioral Health will be the primary care manager for a panel of members with complex behavioral health and substance use disorders. Care coordination activities will focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care.

If you are willing to work 9:30am-6pm Mountain Standard Time, you will have the flexibility to work remotely* as you take on some tough challenges

Primary Responsibilities:

• Provide consultation to providers and/or consumers on a variety of issues including benefit information, safety issues, confirmation of prior authorizations and approvals, procedures for higher levels of care evaluations, and request for an explanation of the level of care, coverage determination, or best practice guidelines
• Respect confidentiality and maintain confidences as described in the UHG Employee Handbook and acknowledged through signature by all employees. The ability to maintain confidentiality is a critical and essential component of this position
• Support outcome focused, evidence-based best practices and guidelines with providers 
• Establish and maintain professional working relations with referral sources, community resources, and care providers and be able to identify and communicate network gaps
• Appropriately identify the need for higher level reviews such as staffing, peer review, or MD consultation. Formulate concise case overviews
• Provide management of behavioral health services, including crisis assessment and intervention
• Process pre-authorization and notification of inpatient and other treatment services
• Oversee initial inpatient admission for psychiatric and chemical dependency patients and provide concurrent review of inpatient and other treatment services
• Conduct patient assessments and determine appropriate levels of care
• Administer benefits, review treatment plans, and coordinate transitions between various areas of care
• Obtain information from providers on outpatient requests for treatment
• Work with consumers and providers to identify and help fill gaps in care and to help consumers move through the continuum of care as appropriate
• Handle escalated calls and resolve complex issues. Ensure issues or changes are communicated and integrated as appropriate
• Utilize individual thought to organize and validate data and develop reports s (e.g., production reports, utilization reports, compliance reports for internal and external audits, and validation of bed days per thousand)
• Utilize clinical knowledge and critical thinking to apply evidence-based guidelines to clinical scenarios to determine medical appropriateness and appropriate level of care

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 licensure as a Registered Nurse in the state of Colorado 
• 3+ years of clinical experience 
• 1+ years directly serving individuals with behavioral health conditions (mental health / substance use disorders)
• 1+ years of experience with MS Office, including Word, Excel, and Outlook
• 1+ years of utilization management experience
• Willing or ability to work 9:30am – 6pm Mountain Standard Time 

Preferred Qualifications:

• CPC licensure 
• CCM certification 
• Experience with electronic medical records
• General prior authorization coding knowledge
• ICD-10, CPT and HCPCS coding knowledge
• Knowledge of evidence-based criteria
• Knowledge of regulatory standards such as CMS, Colorado State Medicaid, Colorado Division of Insurance and NCQA standards
• Background in Managed Care 
• Proven ability to work independently 

*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.

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: 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.