Outpatient RN Case Manager - Remote in San Diego, CA

Optum CA is seeking an Outpatient Case Manager to join our team in San Diego, CA. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

Reviews contracted Medical Group’s authorization requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed decision. Processes all requests within established timeframes. Documents all steps of process in authorization system, utilizes industry standard denial language for denial letters. The work schedule will be Monday through Thursday 6:30am-5pm

Reviews contracted Medical Group’s referral requests for medical necessity. Consideration is given to the appropriateness of the setting, place of service, health plan’s benefits and criteria of the requested services and utilizes service matrix for contracted providers. Documents process in authorization notes Refers all medical necessity denials to the physician for review. Processes denials within establishes timeframes. Documents in the authorization system the denial reason, utilizing the industry standard denial letter language, outlines alternative services available Reviews requests within established timeframes for urgent, routine and retro requests to maintain compliance with legislative and accreditation standards Obtains additional information for review of appeals. Coordinates with health plan to meet timeframes for expedited appeals 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.