Remote Utilization Review RN Manager, Swansea, IL

Optum

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Requisition Number: 2177998
Job Category: Nursing
Primary Location: Swansea, IL
(Remote considered)

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Provides managerial oversight of utilization management staff using established policies, processes, and standards of work to ensure adherence. The UM Manager ensures the team is meeting benchmarks for quality, productivity, and proficiency. Participates in or initiates continual process improvement initiatives, data collection or audit activities, departmental meetings, or other related activities at the request of the Director. Oversight of new hire orientation. Accountable for staff coaching, performance improvement and corrective action processes as appropriate. Conducts annual performance reviews. Escalates challenges, barriers, or process issues to the Director in a timely manner.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

 

Primary Responsibilities:

  • Professional Accountabilities
    • Maintain professional and concise communication skills when engaging front line staff, physicians, or insurers
    • Ensure staff follow established standards of work applicable to the role
    • Ensure department meets established metrics for accuracy and productivity
    • Lead or participates in continuous performance or process improvement based on identified trends or opportunities

  • Utilization Management
    • Oversee and Supervise staff accountabilities as defined below. Take appropriate action when performance or process issues arise in collaboration with the Director
    • Assess all new inpatient admissions for identification of status and admission necessity and make initial proactive UR contact with appropriate Payor
    • Select the appropriate criteria set based on clinical findings at the time of review. Review should include clear documentation of data supporting the proposed level of care
    • Document findings in the client’s EMR per established standards of work
    • Assess the continuity of care daily in conjunction with the Case Managers and Social Workers regarding the continued medical necessity of hospitalization and the status of the discharge plan and communicates this to the Third-Party Payor
    • Coordinate with other Case Management staff to help identify and control inappropriate resource utilization
    • Ensure that concurrent admission and continued stay reviews are based on appropriate utilization review criteria.  Ensure calls are returned on the same day when possible, and no later than the next business day
    • Utilize time constructively and organize assignments for maximum productivity
    • Utilize information provided by the Financial Counselors/Admissions regarding authorized length of stay and follows up with third-party payors on an ongoing basis, and documents in Bar the communications regarding continued authorizations
    • Follow up on denials communicated to the department and works with the Patient Accounting staff to assist with appeals
    • Administer denial of stay letters to patients as indicated
    • Maintain and demonstrate appropriate clinical knowledge to help physicians provide documentation of illness severity and intensity of service to assure that criteria for acute hospitalization are met
    • Employees comply with all regulatory requirements, including CMS and Joint Commission Standards

 

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:

  • Registered Nurse (RN) State Licensure or Compact State Licensure
  • 5+ years of Utilization Management/Review experience
  • Supervisory or Managerial experience

 

Preferred Qualifications:

  • Bachelor or Master of Science Degree
  • Certification in CCM (certified case manager) ACM (Accredited Case Manager), MCG or InterQual
  • Ability to compile, evaluate and present clinical information to justify hospitalization to Third-Party Payors and/or support staff in the completion of these activities
  • Demonstrated Knowledge/understanding of InterQual and MCG clinical criteria of medical necessity

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy