Put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. As a Utilization Management Nurse at UnitedHealth Group, you will make sure our health services are administered efficiently and effectively. You'll assess and interpret member needs and identify solutions that will help our members live healthier lives. This is an inspiring job at a truly inspired organization. Ready to make an impact?
The Utilization Manager (UM) is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. The UM also ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, procedures, diagnostics as well as appropriateness of treatment. Will also partner with medical director to interpreting appropriateness of care and accurate claims payment.
Care coordination or discharge planning for appropriateness of treatment setting
Identify, request and/or obtain additional clinical and/or non-clinical information as needed to make an appropriate determination for medical claims
Ensure or audit to ensure? cases meet applicable clinical and/or administrative criteria, as defined by relevant references/resources (e.g.WTC HP Codebooks and policy manuals, CMS Guidelines, coding manuals)
Identify cases which warrant assignment to Medical Directors, forward as needed, and review the outcome of their determination
Perform initial assessment of appeals cases to determine next steps
Make determinations for administrative cases at the nurse level about whether the appeal should be approved or denied, based on available analyses/research of applicable information
Take appropriate steps based on case determination by the Medical Director or nurse (e.g., denial upheld, overturned, dismissed, pended for additional action)
Ensure that members/providers obtains a full and fair review of their appeal or grievance (e.g., by requesting, obtaining, documenting and/or communicating pertinent information for case files)
Document final determination of appeals or grievances using appropriate platforms, templates, communication processes, etc.
Communicate determinations to relevant stakeholders, as applicable (e.g., appellants, providers)
Reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, as it relates to the WTC contract
Responsible for completing prior authorizations as it relates to the WTC contract
Exercises independent judgment and decision making in determining appropriate treatment avenues (Code request)
Completion of applicable code requests as a result from a denied claim
Demonstrate understanding of business implications of clinical decisions to drive high quality of care
Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS,NCQA/URAC accreditation)
Ask critical questions to ensure member- and customer-centric approach to work
Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes
Use appropriate business metrics to optimize decisions and clinical outcomes
Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up
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.
Associate degree in Nursing degree or higher nursing degree
Current license or able to obtain RN licensure in Texas
Minimum of 2 years acute care clinical experience
Familiarity with ICD10 coding
Utilization Management Experience
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
Experience with Outpatient Nursing (i.e. Durable Medical Equipment, Home Care, Physical Therapy, Occupational Therapy, Speech Therapy)
Must have knowledge of medical management process and ability to interpret and apply member benefits as it relates to the contract.
Must be able to problem solve in a fast paced environment, multitask, and meet tight deadlines
Ability to perform detailed work with a high degree of accuracy
Prior managed care experience strongly preferred
Understanding of regulatory standards and WTC contract requirements
Knowledge of analyzing and reporting statistical data a plus
Join us and discover how a superior professional environment and incredible opportunities make a difference in the lives of patients. We're a place where leaders thrive, and innovation abounds. Seize this opportunity to achieveyour life's best work.(sm)
Careers with LHI. Our focus is simple. We're innovators in cost-effective health care management. And when you join our team, you'll be a partner in impacting the lives of our customers, and employees. We've joined OptumHealth, part of the UnitedHealth Group family of companies, and our mission is to help the health system work better for everyone. We're located on the banks of the beautiful Mississippi River in La Crosse, Wis., with a satellite office in Chicago and remote employees throughout the United States. We're supported by a national network of more than 25,000 medical and dental providers. Simply put, together we work toward a healthier tomorrow for everyone. Our team members are selected for their dedication and mission-driven focus. For you, that means one incredible team and a singular opportunity to do your life's best work.SM
OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.
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
Job Keywords: Utilization Manager, LHI World Trade Center Program, La Crosse, WI, Wisconsin
La Crosse, Wisconsin, United States
The Content Marketer is an individual who has a deep passion for telling the business brand?s story in order to educate the business?s audiences across a...
From Getyourquote Llc - Colorado
Published a month ago
Description: Full time employment for individual who is responsible for preparing cost estimates by analyzing proposals and requirements for the various lines...
From Soar365 - Virginia
Published a month ago
At Thermo Fisher Scientific, each one of our 65,000 extraordinary minds have a unique story to tell. Join us and contribute to our singular mission?enabling our...
From Thermo Fisher Scientific - Tennessee
Published a month ago
The NOC Manager is directly responsible for the day to day activities of the team including operators, analyst or engineers responsible for performing the...
From Unitedhealth Group - Massachusetts
Published a month ago