Requisition Number: 2197789
Job Category: Nursing
Primary Location: Pittsburgh, PA
Opportunities at Northern Light Health, in strategic partnership with Optum. Whether you are looking for a role in a clinical setting or supporting those who provide care, we have opportunities for you to make a difference in the lives of those we serve. As a statewide health care system in Maine, we work to personalize and streamline health care for our communities. If the place for you is at a large medical center, a rural community practice or home care, you will find it here. Join our compassionate culture, enjoy meaningful benefits and discover the meaning behind: Caring. Connecting. Growing together.
Summary: The Utilization Management RN provides feedback as requested to enhance negotiations with payers. Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent, and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation and support of medical necessity/level of care. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities.
Schedule: Variable: Between the hours of 7:00am to 5:00pm EST Monday to Friday with holiday and weekend rotations
You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
- Validates authorization for all procedure / bedded patients UM pre-admission
- Ensuring acquisition of pre-certification authorization, urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services from third-party payers
- Obtains commercial payer authorization within the contractual timeframe at time of presentation, every third day, or as needed
- Proactively reduces the risk of denials
- Manages concurrent cases to resolution
- Partners with Revenue Cycle team to support resolution of retrospective denials
- Conducts initial review and continued stay review every third day for Medicare
- Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information
- Confirms that orders reflect level of care, severity of illness and intensity of service utilizing Level of Care Criteria.
- Establishes and communicates estimated Length of Stay (LOS) using Geometric Mean Length of Stay (GMLOS)
- Conducts Level of Care review using electronic system and documents outcomes. Contacts payers as applicable
- Refers cases with failed criteria to Physician Advisor and appeals as necessary
- Completes stratification tool to identify simple vs complex patient population
- Deploys representative within Utilization Review team to handle audits (internal and external)
- Responsible for coordinating and conducting utilization / medical necessity reviews for all payers upon admission & concurrently throughout the inpatient admission in compliance with the NL EMMC Utilization Management Plan
- Ongoing collaboration with Care Manager to ensure that patient’s condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care
- Performs other duties as assigned or required
What are the reasons to consider working for UnitedHealth Group? Put it all together – competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:
- Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
- Medical Plan options along with participation in a Health Spending Account or a Health Saving account
- Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
- 401(k) Savings Plan, Employee Stock Purchase Plan
- Education Reimbursement
- Employee Discounts
- Employee Assistance Program
- Employee Referral Bonus Program
- Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
- More information can be downloaded at: http://uhg.hr/uhgbenefits
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.
- Associate Degree or higher in Nursing
- Current, unrestricted RN Compact State Licensure or unrestricted RN license in state of residence and ability to obtain a Maine license
- 3+ years of acute clinical practice or related health care experience
- 1+ years of Utilization Management RN or Case Management experience
- Bachelor’s Degree in Nursing (BSN)
- ACM, CCM or other certification applicable to utilization management within 3 years of hire
- Certified Case Manager (CCM)
- Experience or exposure to discharge planning
- Experience in utilization review and concurrent review
- Strong communication and interpersonal skills, including ability to work collaboratively and cooperatively within a team including internal and external customers
- Strong organizational skills and ability to set priorities
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island or Washington Residents Only: The salary range for California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island or Washington residents is $56,300 to $110,400 per year. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
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