Utilization Management Nurse RN

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.

If you hold a Active, Unrestricted Compact State RN License, you will have the flexibility to work remotely* as you take on some tough challenges.

Utilize the designated medical criteria and those of other regulatory bodies, (i.e. NCQA, DOH), the exempt and focused review programs, and the patient’s benefit plan summary to perform medical necessity, level of service and appropriateness review. Perform inpatient and outpatient pre-admission, concurrent review and decision support based on medical necessity, appropriateness of treatment setting and length of stay utilizing criteria and/or community standards and professional judgments. Document timely and concise information which clearly outlines the utilization review strategy online. Accurately apply benefit language to each review situation. Identify any cases that are at high-risk for complex discharge planning or case/risk management intervention and make appropriate referrals. Perform utilization reviews for complex medical conditions such as Transplants and NICU inpatient to meet the needs of internal and external customers. Perform utilization reviews and assist with Transition of Care to meet the needs of internal and external customers. Perform Pre-Service and Post-Service Appeal reviews. Refer cases that do not meet medical necessity criteria to a medical reviewer for medical necessity determination. Coordinate peer review, medical determination and appeal. Identify before or at the time of admission, any cases which have high case management potential due to large dollar amounts, utilization of out of network provider, multiple providers requiring care integration, or complex discharge planning needs. Identify and appropriately transfer cases for Chronic Illness Management or Complex Case Management/Behavioral Health Case Management as appropriate. Work collegially with providers, requesting, providing, and collaborating in obtaining information as needed. In a timely fashion, contact Manager and Account Manager to make recommendations for flexing or extending benefits to prevent the possibility of using more costly services with equivalent outcomes. Assist with the development of policies, procedures, criteria, exempt and focused review programs etc., as required, refine and revise the risk management process to better meet its dual goals of cost efficiency and quality care delivery. Through collaboration and sharing of information, work with other Optum staff to assist in identifying and solving problematic issues through provider education, contracting issues, focused review programs, etc. Review claims, data from pharmacy benefit administrators and other information available to assess patients who have high case management potential or who would benefit from further integration of medical services. Monitor case information for quality and patient safety issues and refer as needed per company guidelines for further review. Ad hoc activities as designated by management, i.e. training and orienting other staff, arranging in-services, researching clinical information on the internet.