Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together. Position in this function is responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. The Concurrent Review/UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Generally, work is self-directed and not prescribed. The Concurrent Review/Utilization Management Nurse works under the direct supervision of an RN or MD.If you have a Compact License, you will have the flexibility to work remotely as you take on some tough challenges.Primary Responsibilities:
Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria
Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
Answers Utilization Management directed telephone calls, managing them in a professional and competent manner
Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turnaround times
Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member
May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department
Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies
Documents rate negotiation accurately for proper claims adjudication
Identify and refer potential cases to Disease Management and Case Management
Performs all other related duties as assigned
The position requires Saturday and/or Sunday shifts/additional weekend shifts will be required as determined by the business.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 or compact license
2+ years of experience in managed care OR 5+ years nursing experience
Proficient in PC software computer skills
Preferred Qualifications:
Authorization experience
Telephonic or telecommute experience
Utilization review or management experience
ICD-10, CPT coding knowledge or experience
InterQual or Milliman knowledge or experience
Proven problem solving and analytical skills
Demonstrated excellent communication skills both verbal and written skills
Demonstrated ability to interact productively with individuals and with multidisciplinary teams with minimal guidance
Demonstrated planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter PolicyAt 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.
Full-time