Utilization Management Registered Nurse - Optum

HCBS Utilization Management Nurse

$5,000 Sign-on Bonus for External Candidates

Optum Home & Community Care, part of the Optum family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere. As a team member of our Optum Care at Home team, together with an interdisciplinary care team we help patients navigate the health care system and connect them to key support services. This preventive care can help patients stay well at home. This life-changing work adds a layer of support to improve access to care. We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

HCBS Utilization Management Nurse Position requires a District of Columbia RN License. This role works under the direct supervision of the DC Manager of Utilization Management, and is responsible for performing pre-service clinical coverage review of Private Duty Nursing (PDN) and Personal Care services (PCS) and other HCBS benefits using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of these services following evaluation of medical guidelines and benefit determination.

This role requires a high degree of coordination with external and internal business partners, including, but not limited to the UnitedHealthcare clinical services inpatient, intake/prior authorizations, appeals and grievance, quality, case and disease management, behavioral health, and other clinical specialties, external HCBS providers and vendors and, or national programs.

If you are located in Washington, DC area, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

• Intake of provider, care coordinator, and Continuity of Care HCBS (home and community-based service) assisted technology and environmental modifications authorization requests
• Review and processing of HCBS authorizations including SMW (Services My Way) budget review request
• Assist case management to determine approval and interventions needed, for the determination of medical necessity, appropriateness of HCBS services
• Engage with the National Letter Team to complete mailing of member and provider notification of decision
• Engage / follow-up with Medical Director to provide clinical information needed for review and application of clinical criteria for PDN request
• Works closely with medical director when issues and concerns regarding the appropriateness, quality or efficiency of care delivery are identified
• Engage / follow-up with Care Management for assessment of member care needs
• Extensive knowledge of the continuum of care
• Participate in planning and attending UM meetings, including CUE and Grand Rounds.
• Participates in state and internal audits and complies with all UM reporting requirements
• Always conduct themselves in a professional manner
• Work closely with the HCBS Review Manager on HCBS issues and concerns
• Perform additional utilization management related duties as assigned

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.

Required Qualifications:

• Unrestricted RN license in the District of Columbia
• 2+ years of clinical experience in health care clinical settings
• 2+ years working in a managed care setting
• 2+ years of utilization management experience
• Demonstrated intermediate-Advanced proficiency experience with Microsoft Office Suite programs (Word, Excel, Outlook)

Preferred Qualifications:

• Experience working with HCBS authorizations and communicating with HCBS providers
• Demonstrated knowledge of District of Columbia Medicaid
• Proven knowledge of Utilization Management and authorization processes
• Experience in a work from home environment
• Training in Interqual and/or MCG Guidelines

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 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. 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.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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