The Integrated Care Team is a cross-functional approach, supporting the member end to end, with close collaboration and co-management. The team will manage the full array of health care services, spanning both outpatient and inpatient settings and with support from some specialized clinical teams. This new cross-functional collaboration provides an opportunity to deliver the next generation clinical model, integrating services from precertification, inpatient concurrent review, discharge planning, care management and prevention to improve quality of care and patient outcomes.
As a Utilization Management RN , you will be responsible for ensuring proper utilization of our health services. This means you will be tasked with assessing and interpreting member needs and identifying solutions that will help our members live healthier lives. This is an inspiring job at a truly inspired organization.
If you are located in North Carolina, you will have the flexibility to telecommute* as you take on some tough challenges.
- Perform initial and concurrent review of inpatient cases applying evidence-based criteria for approval and sending to Medical Directors if review is necessary for determining an adverse determination
- Discuss cases with facility healthcare professionals to obtain plans-of-care
- Collaborate with Medical Directors on performing utilization management
- Participation in discussions with the Clinical Services team to improve the progression of care to the most appropriate level
- Consult with the Medical Director as needed for complex cases and make appropriate referrals to sister segments
- Apply clinical expertise when discussing case with internal and external Case Managers and Physicians
- Identify delays in care or services and manage with MD
- Follow all Standard Operating Procedures in end to end management of cases
- Obtain clinical information to assess and expedite alternate levels of care
- Facilitate timely and appropriate care and effective discharge planning
- Participate in team meetings, education discussions and related activities
- Maintain compliance with Federal, State and accreditation organizations
- Identify opportunities for improved communication or processes
- Participate in telephonic and in-person staff meetings
- Plan for InterQual training
- Build and maintain relationships
- Gather clinical information to assess and expedite care needs
- Maintain appropriate and accurate documentation
- Bachelor’s Degree
- A current, unrestricted RN license in the state of North Carolina
- 3+ years total RN experience
- Demonstrate a proficiency in computer skills – Windows, IM, Excel (Microsoft Suite), Outlook, clinical platforms
- Have a designated workspace and access to install secure high-speed internet via cable / DSL in home
- Must reside in the state of North Carolina
- Hours required within 8:00am to 6:00pm EST
- If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders
- Utilization Mangement/Utilization Review experience
- Preservice Review/Prior Authorization experience
- Experience in discharge planning and/or chart review
- Familiarity with InterQual or MCG criteria guidelines
- Familiarity with CMS guidelines/regulations
- Familiarity with Medicaid guidelines/regulations
Careers with Optum. Here’s the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world’s large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life’s best work.(sm)
- All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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.