[Hiring] Inpatient Utilization Management Nurse RN @UnitedHealth Group

Role Description

The Utilization Review Nurse, RN is responsible for providing clinically efficient and effective inpatient utilization management. Key responsibilities include:

• Reviewing inpatient criteria for acute hospital admissions and concurrent review or prior authorization requests.
• Applying evidence-based clinical guidelines, medical necessity criteria, and health plan guidelines.
• Assuring that patients receive high-quality, cost-effective care.
• Preparing cases that do not meet medical necessity guidelines for review with the Medical Director.

Required hours are 8am-5pm in PST or MST, including one weekend day after the 3-6 month training period. Training will be Monday-Friday 8am-5pm PST before moving to your regular schedule.

You’ll enjoy the flexibility to work remotely from anywhere within the U.S.

Primary Responsibilities:

• Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena.
• Performs clinical review for appropriate utilization of medical services.
• Authorizes healthcare services in compliance with contractual agreements and medical necessity criteria.
• Documents clinical reviews in care management system.
• Utilizes care management system to track and analyze utilization, variances, and trends.
• Researches and prepares clinical information for case review with Physician Leadership.
• Identifies members appropriate for care coordination programs.
• Successfully completes Interrater Reliability Testing.
• Meets timeliness standards for decision, notification, and prior authorization activities.
• Serves as an advocate for all providers and their patients.
• Maintains confidentiality of all company procedures and patient information.
• Performs other duties as required in a positive and helpful manner.

Qualifications

• Current unrestricted Registered Nurse (RN) license in state of residence.
• 3+ years of clinical nursing experience in acute care hospital or LTAC setting.
• 1+ years of Utilization Management experience in hospital or insurance setting.
• Experience applying Medicare and/or Medicaid guidelines.
• Experience with Milliman (MCG) or InterQual guidelines.
• Experience researching and preparing clinical information for case review.
• Experience providing accurate and timely documentation in care management systems.
• Experience employing analytical skills for quality case management and utilization review.
• Experience using various computer software applications, including Microsoft Word and Excel.
• Ability to work Monday-Friday 8am-5pm in Pacific or Mountain Time Zone.

Preferred Qualifications

• Inpatient Utilization Management experience.
• Utilization Management experience for insurance or managed care organization.
• Prior Authorization experience.
• Primary residence in Pacific Time Zone or Mountain Time Zone.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution.

Application Deadline

This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected.