Utilization Management & Clinical Validation RN 2378114 | Newtown Square, Pennsylvania | Remote

Utilization Management & Clinical Validation Rn

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.

The Utilization Management & Clinical Validation Rn will accurately and efficiently review and extract pertinent case details from patient medical records; and craft strongly defensible appeal letters per process instructions and the department's/company's guidance. They will have a working knowledge encoder use and selecting appropriate, supportable appeal arguments from evidence-based, peer reviewed medical literature as provided as well as interpreting and utilizing ICD 9 and 10, CM and PCS, CPT coding system, and HCPCS guidelines. They will recommend changes to coding which will retain, lessen, or increase financial impact when analysis of chart indicates opportunities. The Appeals nurse will perform their job functions, adhering to both Optum and OPAS policies and procedures, which include but are not limited to the following:

• Adheres to approved schedule and arrives to work timely
• Maintains accurate accounts of time off in both Verint and HR Direct as per guidelines, and follows directives for time off, schedule changes, etc.
• Follows directive of composing appeal letters to include appropriate data extraction, construction of well-written appeals letters with proper grammar, utilization of appeal tools including pre-constructed templates, and inclusion of appropriate medical literature references
• Use and fluency of encoders, coding clinics, ICD-9 and 10 guidelines, CM and PCS, CPT coding system and HCPCS guidelines
• Working knowledge of Word
• Effective communication skills
• Excellent typing skills with a minimum of 45/min speed
• Adheres to company policies and procedures as well as policies, procedures, and laws
• Understands and complies with HIPAA confidentiality requirements
• Support and promote OPAS, Optum, and the enterprise goals and mission
• Build relationships across Optum, OPAS, OGA and our clients
• Collaborate with peers to assure continuity of communication and execution of deliverables as needed
• Adheres to quality and productivity expectations
• Participate in and contribute to meetings as appropriate
• Maintains organization on the team and ensures everyone conducts themselves professionally
• Remains up to date with all learning modules, competencies, and state required licenses
• Performs other related duties, tasks, and processes as required by leadership
• Ability to establish priorities, be self-motivated, work independently, and follow instructions with supervision and structure
• Positive attitude and the ability to function as a collaborative team member

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Associates degree or higher
• Unrestricted RN license required in state of residence
• 3+ years of Clinical experience in ED/Telemetry/Critical Care
• 2+ years of experience in clinical validation appeals

Preferred Qualifications:

• Pre-authorization experience
• License certified coder
• Utilization Management experience
• Case Management experience
• Knowledge of Milliman Criteria
• Certified Case Manager (CCM)

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. 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: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.