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Positions in this function is responsible for timely, accurate medical review, determining if requests for services to be provided to The Group patients meet criteria for coverage based upon medical policies, guidelines, and health plan criteria. Responsible for review of inpatient length of stay for compliance with medical policies, guidelines, and health plan criteria. Based on criteria may refer cases to Medical Director Care Management for further review. Ensures compliance to contractual and service standards as identified by relevant health insurance plans and The Group.

This is performed under the direct supervision of the Medical Director, Care Management. Adheres to policies, procedures and regulations to ensure compliance and patient safety. Participation in Compliance and other important training is a condition of employment.

If you are Compact State License and able to work in Mountain Time Zone, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Provides timely, accurate review of precertification and prior authorization requests, for compliance with applicable medical policies and health plan benefits 
• Provides concurrent medical review of inpatient length of stays to ensure compliance with applicable medical policies and health plan benefits
• Providing both outpatient and inpatient medical management review as needed, to ensure that patient healthcare requirements and organizational goals are met in a reasonable and medically appropriate manner
• Ensure communication regarding medical reviews are provided to relevant patients and Providers in a timely manner, and in compliance with contractual agreements
• Ensures compliance with HIPAA and other applicable company policies and procedures as well as regulatory requirements
• Identify and address opportunities for quality improvement in all aspects of serving our customers. Assist in planning and implementation of systems changes and procedures to achieve overall organizational objectives
• Maintain effective communication with management regarding development within areas of assigned responsibilities and performs special projects as required
• MCG certification within one year of hire
• Performs other duties as assigned

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:

• Associates degree in Nursing
• Valid, unrestricted, NM RN License, UT License, ID License or valid multi-state compact license
• 3 years of job-related experience in a healthcare environment
• Working knowledge of HMO’s, PPO’s, Medicare, Medicaid, and insurance plans
• Knowledge of CPT4/ICD 9 & 10/HCPCS codes
• PC proficient
• Demonstrated ability to communicate and interact professionally with co-workers, management patients, and Providers
• Demonstrated ability to counsel and/or consult
• Must pass a nationwide criminal history screen through the Caregivers Criminal History Screening Program

Preferred Qualifications:

• Bachelor’s degree in Nursing
• Utilization Review or Case Management Certificate
• 2 years of experience providing case management and/or utilization review functions within health plan or integrated system

*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: 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.