Utilization Management Nurse – Remote in PST

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. 

Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions. 

The Utilization Management Nurse will conduct reviews of requested healthcare services and determine medical appropriateness of inpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures. This position collaborates with medical directors, facility case management and utilization management, and stakeholders to provide the level of care necessary to meet the members’ needs. The UM Nurse provides planning and care coordination to facilitate transition plans to the appropriate level of care across the care continuum. 

If you are located in PST, you will have the flexibility to work remotely* as you take on some tough challenges. Must be able to work 8am-5pm PST.

Primary Responsibilities:

• Communicates directly with providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
• Performs utilization and concurrent reviews of all inpatient stays using evidence-based criteria, approves bed days, identifies and evaluates delays in care, initiates discharge planning, arranges alternative care settings when medically appropriate
• Manages and follows relevant time frame standards for conducting and communicating utilization review determinations
• Works closely with relevant medical entities to assure members are transitioned to appropriate levels of care and all supporting resources are available either through the healthcare benefits or other supporting entity
• Prepares for oversight audits by the health plans and responds to appeal requests 
• Monitors and evaluates medical services and community-based resources to meet the individual member’s health needs at time of care transitions
• Follow up with ancillary contracted entities if services or resources have not been made available to the member to assure that medical needs are being met
• Makes appropriate care management referrals through triage process during care transition to case management staff
• Reviews written requests for clinical services for medical appropriateness
• Interfaces with referring practitioners or staff, to facilitate care alternatives within specified time restrictions
• Facilitates understanding in the areas of case management, quality management, utilization management, member education and preventive health guidelines to promote health plan expectations and refers members for appropriate services
• Responds to questions from medical offices and hospitals about the necessary steps of the medical referral authorization process
• Manages utilization review authorizations, both verbal and written to assure high continuity of care for all managed care members in the program and consistency of gathering specific information within the department to comply with policies and procedures
• Review and respond to all reconsideration and appeal requests within timeframes outlined by the health plan
• Works closely with the CMO to obtain timely medical decisions on pended referrals and requests for medical services from health plans and providers

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:

• Graduation from an accredited school of nursing
• Active, unrestricted Registered Nurse license in State of Hire
• 2+ years of experience in Utilization Review for Insurance or Community Based facility
• 2+ years of clinical nursing experience

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

The salary range for this role is $59,500 to $116,600 annually 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 employers 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.