Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. 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.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Must be in either Pacific or Mountain time zones work 8am - 5pm Mon-Fri in those time zones.

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 customer
• Perform all functions of the UM nurse reviewer
• Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards
• Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request
• Ensures the denial reason is in the appropriate grade level and is easily understandable
• Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial
• Selects the correct level of hierarchy and applied correctly based on the medical information available
• Provides relevant clinical information to the request and the criteria used for decision-making
• Ensures 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 applied
• Evaluates out-of-network and tertiary denials for accessibility within the network
• Performs a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelines
• Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination
• Escalates non-compliant cases to UM compliance and consistently reports on denial activities
• Collaborates with UM compliance for continued quality improvement efforts for adverse determinations
• Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution
• Meets or exceeds productivity targets
• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Performs additional 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: 

• Graduation from an accredited school of nursing.
• Active, unrestricted Registered Nurse license through the State of Washington or a valid, unrestricted compact nursing license
• Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross).
• 1 years of experience in Utilization

Preferred Qualifications:

• Bachelor of Science in Nursing, BSN
• 3 years of prior acute care, care management, utilization review or discharge planning experience
• HMO experience
• Live and work in either the Pacific or Mountain time zones

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for this role is $58,300 to $114,300 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.