RN, Utilization Management Nurse - Remote

1 week ago Be among the first 25 applicantsGet AI-powered advice on this job and more exclusive features.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.Position in this function is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making as it relates to the application of criteria and defined levels of hierarchy and composition of regulatory requirements.If you have an active RN License in CA and able to work Pacific Standard Time (PST), you will have the flexibility to work remotely* as you take on some tough challenges.Primary ResponsibilitiesPerforms all functions of an UM NurseConsistently exhibits behavior and communication skills that demonstrate OPTUM's commitment to superior customer service, including quality, care and concern with each and every internal and external customerImplements current policies and procedures, standardization requirements set by the Utilization Management and by the UM Compliance departmentImplements and maintains regulatory turnaround timesResponsible for implementing accuracy and accountability of the information provided when prepping referral requests for medical necessity and redirection within primary network with CMS and health plan appropriate guidelinesReviews patient referrals within the specified utilization management policy and regulatory compliance timeframes, manages production and ensures services to our providers and patients in a timely manner (Type and Timeline Policy)Assures that they utilize Standard Documentation when prepping referrals for processingCommunicates authorization or denial of services to appropriate parties Communication may include patient (or agent), referring physician, and Optum claims as necessaryDemonstrates a thorough understanding of the cost consequences resulting from utilization management decisions through utilization of appropriate reports such as Health Plan Eligibility andBenefits, Division of Responsibility (DOFR)Ensures appropriate utilization of medical facilities and services within the parameters of the patients' benefits and/or CMC decisionsMaintains effective communication with the health plans, physicians, hospitals, patients and familiesMeets or exceeds all productivity standards set by your managerMaintains accurate and complete documentation of care rendered including POS, CPT Code, ICD-10, referral type, date, etcCompletes and passes IRR (Interrater Reliability) at prescribed intervals per ManagementAttends all educational webinars and/or views on the SharePoint and takes knowledge checks as per Management and UM Education directionUses, protects, and discloses Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standardsPerforms additional duties as assignedYou'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 QualificationsGraduation from an accredited school of NursingCurrent California RN licensePreferred Qualifications2+ years of Prior Authorization UM experienceAll employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter PolicyThe hourly range for this role is $28.61 to $56.06 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.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.UnitedHealth Group 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.UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.Seniority level Seniority level Entry levelEmployment type Employment type Full-timeJob function Job function Health Care ProviderIndustries Hospitals and Health CareReferrals increase your chances of interviewing at Optum by 2xGet notified about new Registered Nurse jobs in Irvine, CA .Certified Nursing Assistant (CNA) Sub-Acute PEDS - Loan Forgiveness & $6,000 Sign-on Bonus - Full Time, Days (Tustin) Irvine, CA $60,000.00-$118,000.00 8 months agoRegistered Nurse II, FT, Day Shift, 12 Hour Irvine, CA $59,500.00-$116,600.00 18 hours agoRegistered Nurse, Full Time0 Day Shift (8 Hours) Long Beach, CA $77,580.00-$161,878.00 1 month agoOrange, CA $1,847.00-$1,997.00 12 hours agoLong Beach, CA $77,580.00-$161,878.00 5 days agoRegistered Nurse II, FT, Day Shift, 8 Hours Registered Nurse, Full-Time, Night Shift (8 Hours) Registered Nurse II, Full Time, Day Shift, 8 Hours Long Beach, CA $77,580.00-$161,878.00 2 months agoCLINICAL NURSE I (Part Time) - IRVINE CANCER OP TRTMNT CTR We're unlocking community knowledge in a new way. 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