[Hiring] Secondary Review Nurse @UnitedHealth Group

Role Description

The Secondary Review Nurse plays a critical role in evaluating clinical requests for Home and Community-Based Services (HCBS). This position ensures that care provided is medically necessary, cost-effective, and tailored to the individual needs of each member, while remaining compliant with state regulations.

If you reside within the state of Indiana, you will enjoy the flexibility to work remotely as you take on some tough challenges.

Primary Responsibilities:

• Participate in secondary reviews for HCBS services and Medicaid services
• Review and process prior authorization requests for LTSS and HCBS services
• Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services
• Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the members’ service plan
• Monitor utilization patterns and identify opportunities for improved care coordination and cost containment
• Document all clinical decisions and communications in accordance with regulatory and organizational standards
• Support quality improvement initiatives and participate in developing education and training for staff
• Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed
• Stay current with established guidelines and regulatory requirements

Qualifications

• Current, unrestricted RN license for Indiana
• 3+ years of clinical experience in a hospital, acute care, home health/hospice, direct care or case management and the ability to quickly identify needs and issues
• 2+ years of experience with completing functional assessments for LTSS services
• 2+ years of Medicaid, Medicare, or Managed Care experience and with Long-Term Services and Supports
• Intermediate level of knowledge of LTSS experience determining eligibility and appropriate allocation of services
• Intermediate level of computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications

Requirements

• Pre-authorization experience
• Utilization Management experience
• Case Management experience
• Knowledge of state and federal guidelines
• Home health or hospice experience
• Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)
• Hourly pay for this role will range from $29 - $52 per hour based on full-time employment