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.

 

The Case Manager (CM) / Utilization Review (UR) nurse staff augmentation role will temporarily fill in for Optum care management teams for short term staffing as well as provide consultative support to the front-line care management team, as appropriate. During a short-term assignment, the role will provide comprehensive care management or utilization review services in various locations.

 

The Case Manager (CM) is responsible and accountable for coordination of patient services through an interdisciplinary process, which provides a clinical and psychosocial approach through the continuum of care. Through case management, patients will be assessed to determine appropriateness of admission, continued hospitalization, as well as appropriate level of care. Case Managers facilitate timely care delivery at the right time and in the right setting, escalate operational barriers, and collaborate with all stakeholders. Discharge planning will begin at the time of (or prior to) admission and will be reassessed ongoing throughout the course of hospitalization in partnership with the clinical care team, the patient, and/or the patient’s representative. Quality and Risk Management issues will also be monitored for and reported as appropriate.

 

The Utilization Review nurse provides utilization management services, in coordination with other Case Management staff, providers, and other healthcare team members, using pre-established guidelines and criteria to perform review activities to assure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors. The Utilization Review (UR) nurse will proactively provide necessary medical information to justify the medical necessity of the hospital stay and will take necessary follow-up action to assist in the appeal processes of denials.

 

In addition, as required, this individual will provide consulting services in care management redesign with the frontline team members. This individual will work alongside client teams to solve complex business problems, improve performance, and execute high priority initiatives by conducting and/or interpreting analyses, creating deliverables, and helping drive project execution for Optum’s transformational clients.

 

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

 

Primary Responsibilities:

Professional Accountabilities

Adheres to name badge/dress code compliance Effectively problem-solves and actively pursues resolution Directly communicates with staff, physicians, patients, and families Maintains professional and concise telephonic or written communication skills when engaging front line staff physicians or insurers Role models leadership behavior through courtesy, respect, and efficiency Follows established standards of work applicable to role Meets established metrics for accuracy and productivity Participates in continuous performance or process improvement based on identified trends or opportunities Coordinates patient care processes to achieve desired quality outcomes and identifies/controls inappropriate resource utilization Facilitates patient and family education and promotes continuity of care to achieve optimal patient outcomes. Assures patient rights by offering a choice when appropriate Reviews the patient plan of care with the multi-disciplinary team. Facilitates and participates in multi-disciplinary team care conferences for patients with complex problems. Communicates in the medical record and verbally with the team to coordinate interventions and facilitate continuity of care Communicates and collaborates daily with the patient care staff to provide continuous assessment, evaluation, and continuum planning to assure the patient receives the appropriate level of care at the appropriate time. Facilitates the implementation of nursing interventions as indicated by the multi-disciplinary team plan of care that enhances and compliments the skill level of the nursing staff Functions without direct supervision, utilizing time constructively and organizing assignments for maximum productivity. Arranges schedule to facilitate meeting with physicians for patient care rounds, team meetings and other opportunities to improve communication Able to effectively read, write, and speak, cognitively process, and emotionally support performing other duties as assigned Remains flexible to meet the needs of the hospital, which may include floating to other departments to assist as the patient needs fluctuate

Utilization Management

Has knowledge of all applicable federal and state regulations. Demonstrates a working knowledge of managed care and Medicare health plans as well as reimbursement related to post-acute services within the continuum of care Consults with physician section leaders for support in cases that continued stay is not appropriate and case manager is unable to come to resolution by working with assigned physician Responsible for communicating with the department director length of stay (LOS) and financial information, as well as issues that may affect the continuum of care process Assesses planned or admitted designated patient groups for identification of status and admission necessity Selects the appropriate criteria set based on clinical findings at the time of review. Includes clear documentation of the data supporting the proposed level of care Documents findings in the client’s EMR per established standards of work For patients meeting inpatient criteria with an MD inpatient order, ensures initial proactive UR contact with appropriate payor based on established process (for example, fax/portal/phone) Engages attending physicians or ED physicians as appropriate if clinical information is incomplete or needs clarification Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met Engages attending physicians or ED physicians as appropriate if clinical information is incomplete or needs clarification Follows established escalation standard of work for those cases with a mismatch of review finding and physician status order Follows established standards of work for concurrent denials Coordinates with hospital-based Case Management staff to help identify and manage inappropriate resource utilization Independently utilizes time constructively by prioritizing and organizing assignments for maximum productivity Complies with all regulatory requirements, including State and Federal Standards Provides concurrent state review services based on needs/request

Continuum of Care Planning

Responsible for integrating the assessment of the need for post-hospital services and determination of an appropriate discharge plan for complex cases Educates patient/family as to options/choices within the level of care determined to be appropriate. Initiates and insures completion of all necessary paperwork Facilitates completion of orders as required prior to transfer of patient to the next level of care in a timely manner so discharge is not delayed Continuum of Care planning will emphasize education and collaboration with physicians, family members, clinical social workers, nursing staff, therapists, and case managers from contracted payors when appropriate to determine discharge plan that will be of maximum benefit to the patient. Involves staff from next level of care in the treatment plan as early as possible to promote continuity and collaboration Reports all relevant information to the staff assuming responsibility in the next level of care Complies with all regulatory requirements, including CMS and Joint Commission Standards

Risk Management

Interfaces with department directors, Risk Management, and patient representatives to identify potential QA or risk issues. Performs any necessary investigation, documentation and follow-up as required Participates in departmental SQI projects Functionally coordinates and plans discharge for all age groups, including but not limited to the unborn child through geriatric age groups

Consultative Services

Supports front line redesign for care management transformation in conjunction with operations and transformational leaders and team Synthesizes findings and summarizes a broad range of data inputs into outputs that clearly communicate data findings and insights Defines, develops, and documents business requirements to ensure clients' needs are captured and delivered Creates written and oral communication artifacts or deliverables that effectively summarize findings, support fact-based recommendations, and provide appropriate detail to substantiate conclusions Provide any of the following:
Monitor operational or service line agreement metrics for improvement Partner with Optum Education team to develop standard work tools, job aides, or guidelines Provide education to front line care management team members Coach front line team members on new processes or workflows Support implementation of care management processes, such as interdisciplinary rounds or long length of stay rounds observations and auditing Perform chart reviews to assess care management team performance

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 Nursing state license in good standing for state in which services will be performed 3+ years of case management experience in an acute care setting 3+ years of utilization review experience in a hospital or with a third-party payor 3+ years of discharge planning experience Ability to compile, evaluate, and report statistics to members of the team as well as to utilize this information to facilitate process improvement activities Proven effective communication skills for meeting facilitation, educational presentations, team collaboration and patient interviews Proven knowledge/understanding of community resources, policies, and procedures Ability to compile, evaluate, and present clinical information to justify hospitalization to outside third-party payors Proven knowledge of Utilization Review, Medicare requirements processes, as well as State and Federal regulations pertaining to utilization review and discharge planning Demonstrated accuracy and attention to detail in the selection and application of criteria to support level of care Proven knowledge/understanding of InterQual and/or MCG criteria of medical necessity Proven solid analytical, critical thinking and organizational skills Ability to travel up to 100% domestically

Preferred Qualifications:

Case Management Certification Basic Life Support Certification Certification in CCM (certified case manager), ACM (Accredited Case Manager), MCG, and/or InterQual Proven clinical knowledge of the Labor and Delivery, Neonatal, Medical Surgical, Oncology, ICU patient and process Experience as a traveling nurse 

 

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

 

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Maryland, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $88,000 to $173,200 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.