Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation Data gathering requires navigation through multiple system applications Staff may be required to contact the providers of record, vendors, or internal departments to obtain additional information Evaluates documentation/information to dete... more details
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Position in this function is responsible for the review and evaluation of specialty injectable information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.
If you are located in PST time zone states, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
- Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations
- Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation
- Data gathering requires navigation through multiple system applications
- Staff may be required to contact the providers of record, vendors, or internal departments to obtain additional information
- Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines
- Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand
- Commands a comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information
- Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines
- Condenses complex information into a clear and precise clinical picture while working independently
Positions in this function require various nurse licensure and certification based on role and grade level. Licensure includes RN or LPN/LVN, depending on grade level, with current unrestricted licensure in applicable state. LPN/LVN roles work under the direct supervision of an RN or MD. Function is responsible for utilization management which includes Concurrent Review (on-site or telephonic Inpatient Care Management). Performs reviews of current inpatient services. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. *Employees in jobs labeled with SCA must support a government Service Contract Act (SCA) agreement.
- Generally work is self-directed and not prescribed
- Works with less structured, more complex issues
- Serves as a resource to others
Youll 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:
- Undergraduate degree or equivalent experience
- Requires an RN with unrestricted active license
- 3+ years of clinical experience
- Managed Care
- Medicare experience
- Prior Authorization
- Utilization Review
Preferred Qualifications:
- Pharmacy prior authorization review
*All employees working remotely will be required to adhere to UnitedHealth Groups Telecommuter Policy
Nevada, Washington or California Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. 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, youll find a far-reaching choice of benefits and incentives.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyoneof every race, gender, sexuality, age, location and incomedeserves 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: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
