Utilization Management Nurse - Remote

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 Pacific 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.

Position in this function is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices.

If you are located within Lane County Oregon, you’ll enjoy the flexibility to work remotely *as you take on some tough challenges.

Primary Responsibilities : Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customerPerforms all functions of the UM nurse reviewerComposes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standardsConstructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and requestEnsures the denial reason is in the appropriate grade level and is easily understandableEnsures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denialSelects the correct level of hierarchy and applies correctly based on the medical information availableProvides relevant clinical information to the request and the criteria used for decision-makingEnsures that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria appliedEvaluates out-of-network and tertiary denials for accessibility within the networkPerforms a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelinesConsults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determinationEscalates non-compliant cases to UM compliance and consistently reports on denial activitiesCollaborates with UM compliance for continued quality improvement efforts for adverse determinationsIdentifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solutionMeets or exceeds productivity targetsUses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standardsPerforms additional duties as assignedYou’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 nursingActive, unrestricted Registered Nurse license through the State of Oregon1+ years of experience in UtilizationExperience in Skilled Nursing FacilitiesPreferred Qualifications : Bachelor of Science in Nursing, BSN3+ years of care management, utilization review or discharge planning experienceHMO experience*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 : 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