RN, Utilization Management - Remote

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making as it relates to the application of criteria and defined levels of hierarchy and composition of regulatory requirements. If you are licensed in CA, you will have the flexibility to work remotely* from anywhere within the U.S. during Pacific Standard Time zone business hours as you take on some tough challenges.

Performs all functions of an UM Nurse Consistently exhibits behavior and communication skills that demonstrate OPTUM’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer Implements current policies and procedures, standardization requirements set by the Utilization Management and by the UM Compliance department Implements and maintains regulatory turnaround times Responsible for implementing accuracy and accountability of the information provided when prepping referral requests for medical necessity and redirection within primary network with CMS and health plan appropriate guidelines Reviews patient referrals within the specified utilization management policy and regulatory compliance timeframes, manages production and ensures services to our providers and patients in a timely manner (Type and Timeline Policy) Assures that they utilize Standard Documentation when prepping referrals for processing Communicates authorization or denial of services to appropriate parties. Communication may include patient (or agent), referring physician, and Optum claims as necessary Demonstrates a thorough understanding of the cost consequences resulting from utilization management decisions through utilization of appropriate reports such as Health Plan Eligibility and Benefits, Division of Responsibility (DOFR) Ensures appropriate utilization of medical facilities and services within the parameters of the patients’ benefits and/or CMC decisions Maintains effective communication with the health plans, physicians, hospitals, patients and families Meets or exceeds all productivity standards set by your manager Maintains accurate and complete documentation of care rendered including POS, CPT Code, ICD-10, referral type, date, etc. Completes and passes IRR (Interrater Reliability) at prescribed intervals per Management Attends all educational webinars and/or views on the SharePoint and takes knowledge checks as per Management and UM Education direction Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards Performs additional duties as assigned