LTSS Utilization Management, RN - Remote in NM

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care.

The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable.

Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The Senior Utilization Management Nurse will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for complex and / or critical issues.

This position will communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding;

and will provide summary clinical and ancillary information to the Health Plan Medical Director for review and decision making.

If you are located in New Mexico, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities :

• Functional role is responsible for utilization management of LTSS determinations, oversight on outpatient service requests from a reporting perspective and understanding the criteria for inpatient reviews, including concurrent inpatient reviews
• Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review chart / clinical information, ask appropriate questions, and identify appropriate course of care in each situation
• Determines medical appropriateness using medical guidelines and benefit determination
• Solves complex problems and develops innovative solutions
• Ability to oversee and run biweekly meetings for Complex / High Risk members in conjunction with LTSS and Health Services staff
• Reviews work performed by others and, provides recommendations for improvement, including performing annual IRR for LTSS determinations
• Provides explanations and information to others on the most complex issues
• Leverage appropriate clinical terminology when communicating with physicians and other medical professionals
• Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action
• Apply professional judgment, take initiative to follow up, and manage conversations to make sound conclusions / recommendations regarding LTSS patient care or coverage
• Apply information about patient condition and benefit applicability / limitations of coverage to make recommendations

Generally, work is self-directed and not prescribed

• Works with less structured, more complex issues
• Works with minimal guidance; seeks guidance on only the most complex tasks
• Coaches, provides feedback, and guides others
• Acts as a resource for others with less experience
• Anticipates customer needs and proactively develops solutions to meet them
• Prepares reports as directed

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 independent licensure as a New Mexico Registered Nurse
• 3+ years of clinical experience
• 1+ years of Utilization Management experience
• 1+ years of experience with MS Office, including Word, Excel, and Outlook
• 1+ year of experience in HCBS LTSS Care Coordination and LTSS UM Determination
• Background in Managed Care
• Currently reside in New Mexico
• Ability to travel locally up to 10% of the time
• Ability to adhere to a Monday - Friday 8a - 5p MST work schedule

Preferred Qualifications :

• Master's degree or higher in clinical field
• InterQual Certified and / or Milliman (MCG) Certified
• MIDAS experience
• Proficient in ICUE and Community Care
• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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 : 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.