[Hiring] Utilization Management Registered Nurse @UnitedHealth Group

Role Description

The HCBS Utilization Management Nurse Position requires a District of Columbia RN License. This role works under the direct supervision of the DC Manager of Utilization Management and is responsible for performing pre-service clinical coverage review of:

• Private Duty Nursing (PDN)
• Personal Care services (PCS)
• Other HCBS benefits using applicable benefit plan documents, evidence-based medical policy, and nationally recognized clinical guidelines and criteria.

Determines medical appropriateness of these services following evaluation of medical guidelines and benefit determination.

This role requires a high degree of coordination with external and internal business partners, including, but not limited to:

• UnitedHealthcare clinical services
• Inpatient, intake/prior authorizations
• Appeals and grievance
• Quality, case and disease management
• Behavioral health
• Other clinical specialties
• External HCBS providers and vendors
• National programs

If you are located in the Washington, DC area, you will have the flexibility to telecommute as you take on some tough challenges.

Primary Responsibilities:

• Intake of provider, care coordinator, and Continuity of Care HCBS (home and community-based service) assisted technology and environmental modifications authorization requests
• Review and processing of HCBS authorizations including SMW (Services My Way) budget review request
• Assist case management to determine approval and interventions needed for the determination of medical necessity and appropriateness of HCBS services
• Engage with the National Letter Team to complete mailing of member and provider notification of decision
• Engage/follow-up with Medical Director to provide clinical information needed for review and application of clinical criteria for PDN request
• Work closely with medical director when issues and concerns regarding the appropriateness, quality, or efficiency of care delivery are identified
• Engage/follow-up with Care Management for assessment of member care needs
• Extensive knowledge of the continuum of care
• Participate in planning and attending UM meetings, including CUE and Grand Rounds
• Participate in state and internal audits and comply with all UM reporting requirements
• Always conduct themselves in a professional manner
• Work closely with the HCBS Review Manager on HCBS issues and concerns
• Perform additional utilization management related duties as assigned

Qualifications

• Unrestricted RN license in the District of Columbia
• 2+ years of clinical experience in health care clinical settings
• 2+ years working in a managed care setting
• 2+ years of utilization management experience
• Demonstrated intermediate-Advanced proficiency experience with Microsoft Office Suite programs (Word, Excel, Outlook)

Requirements

• Experience working with HCBS authorizations and communicating with HCBS providers
• Demonstrated knowledge of District of Columbia Medicaid
• Proven knowledge of Utilization Management and authorization processes
• Experience in a work from home environment
• Training in Interqual and/or MCG Guidelines

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)

The salary for this role will range from $60,200 - $107,400 annually based on full-time employment.