Utilization Management Nurse - Remote in PST

For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

The Utilization Management Nurse will conduct reviews of requested healthcare services and determine medical appropriateness of inpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures. This position collaborates with medical directors, facility case management and utilization management, and stakeholders to provide the level of care necessary to meet the members’ needs. The UM Nurse provides planning and care coordination to facilitate transition plans to the appropriate level of care across the care continuum. If you are located in PST, you will have the flexibility to work remotely* as you take on some tough challenges. Must be able to work 8am-5pm PST.

Communicates directly with providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services Performs utilization and concurrent reviews of all inpatient stays using evidence-based criteria, approves bed days, identifies and evaluates delays in care, initiates discharge planning, arranges alternative care settings when medically appropriate Manages and follows relevant time frame standards for conducting and communicating utilization review determinations Works closely with relevant medical entities to assure members are transitioned to appropriate levels of care and all supporting resources are available either through the healthcare benefits or other supporting entity Prepares for oversight audits by the health plans and responds to appeal requests Monitors and evaluates medical services and community-based resources to meet the individual member’s health needs at time of care transitions Follow up with ancillary contracted entities if services or resources have not been made available to the member to assure that medical needs are being met Makes appropriate care management referrals through triage process during care transition to case management staff Reviews written requests for clinical services for medical appropriateness Interfaces with referring practitioners or staff, to facilitate care alternatives within specified time restrictions Facilitates understanding in the areas of case management, quality management, utilization management, member education and preventive health guidelines to promote health plan expectations and refers members for appropriate services Responds to questions from medical offices and hospitals about the necessary steps of the medical referral authorization process Manages utilization review authorizations, both verbal and written to assure high continuity of care for all managed care members in the program and consistency of gathering specific information within the department to comply with policies and procedures Review and respond to all reconsideration and appeal requests within timeframes outlined by the health plan Works closely with the CMO to obtain timely medical decisions on pended referrals and requests for medical services from health plans and providers