At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together. The Utilization Management Nurse will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for complex and/or critical issues. This position will communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding; and will provide summary clinical and ancillary information to the Health Plan Medical Director for review and decision making. If you are located in the state of New Mexico, you will have the flexibility to work remotely* as you take on some tough challenges. This position is a remote - based position with a home - based office. Primary Responsibilities: • Function is responsible for utilization management which includes Initial and Concurrent Utilization Reviews for LTSS • Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in a given situation • Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination • Anticipates customer needs and proactively develops solutions to meet them • Solves complex problems and develops innovative solutions • Reviews work performed by others and provides recommendations for improvement • Authorizes deviations from standards • Provides explanations and information to others on the most complex issues • Leverage appropriate clinical terminology when communicating with physicians and other medical professionals • Advocate with physicians and others for appropriate decisions (e.g., patient level of care changes) regarding patient betterment (e.g., care and service coverage, safety) • Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action • Apply professional judgment, take initiative to follow up, and manage conversations to make sound conclusions/recommendations regarding patient care or coverage • Apply information about patient condition and benefit applicability/limitations of coverage to make recommendations • Generally work is self-directed and not prescribed • Works with less structured, more complex issues • Works with minimal guidance; seeks guidance on only the most complex tasks • Coaches, provides feedback, and guides others • Acts as a resource for others with less experience 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.
Optum Home & Community Care is part of UnitedHealth Group and provides telephonic case management services to help members navigate the health care system and access support services. As an RN Case Manager, you would assess members' health status, identify gaps in treatment plans, establish care goals, coordinate with multidisciplinary teams including mental health clinicians, provide patient education and coaching, make referrals to community resources, and facilitate transitions between care settings—primarily through phone calls in a high-volume customer service environment.
