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Utilization Management Registered Nurse

Company: UnitedHealth Group
Location: La Crosse
Posted on: December 8, 2018

Job Description:

Position Description At Optum, the mission is clear: Help people live heathier lives and help make the health system work better for everyone LHI is one of 4 businesses under OptumServe. OptumServe provides health care services and proven expertise to help federal government agencies modernize the U.S. health system and improve the health and well-being of Americans. By joining OptumServe you are part of the family of companies that make UnitedHealth Group a leader across most major segments in the U.S. health care system. LHI was founded in 1999 and acquired by Optum in 2011, LHI specializes in creating and managing health care programs through on-location services, patient-specific in-clinic appointments, telehealth assessments, or any combination based on customer need. LHI's customizable solutions serve the diverse needs of commercial customers, as well as federal and state agencies, including the U.S. Departments of Defense, Veterans Affairs, and Health and Human Services. There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Ready for a new path? Start doing your life's best work.(sm) We are currently seeking an Utilization Management Registered Nurse to join our team in Lacrosse, WI. The Utilization Manager is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. The UM also ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, procedures, diagostics as well as appropriateness of treatment. Will also work with medical director in interpreting appropriateness of care and accurate claims payment. Care coordination, or discharge planning for appropriateness of treatment setting Identify, request and/or obtain additional clinical and/or non-clinical information as needed to make an appropriate determination Determine whether cases meet applicable clinical and/or administrative criteria, as defined by relevant references/resources (e.g.WTC HP Codebooks and policy manuals, CMS Guidelines, coding manuals) Assess which cases warrant assignment to Medical Directors, forward as needed, and review the outcome of their determination Perform initial assessment of appeals cases to determine next steps Make determinations for administrative cases at the nurse level about whether the appeal should be approved or denied, based on available analyses/research of applicable information Take appropriate steps based on case determination by the Medical Director or nurse (e.g., denial upheld, overturned, dismissed, pended for additional action) Ensure that members/providers obtains a full and fair review of their appeal or grievance (e.g., by requesting, obtaining, documenting and/or communicating pertinent information for case files) Document final determination of appeals or grievances using appropriate platforms, templates, communication processes, etc. Communicate determinations to relevant stakeholders, as applicable (e.g., appellants, providers) Reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, as it relates to the WTC contract Responsible for completing prior authorizations as it relates to the WTC contract Exercises independent judgment and decision making in determining appropriate treatment avenues (Code request) Completion of applicable code requests as a result from a denied claim Demonstrate understanding of business implications of clinical decisions to drive high quality of care Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS,NCQA/URAC accreditation) Ask critical questions to ensure member- and customer-centric approach to work Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes Use appropriate business metrics to optimize decisions and clinical outcomes Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up) Please Note: In order to be considered for this position, you must be able to obtain an SF86 Position of Trust which is only available to U.S. Citizens. Our Facilities Security Officer will initiate this process post-offer acceptance. Failure to obtain this will result in termination from this role. Required: Associate Degree in Nursing Minimum of 2 years acute care clinical experience Minimum of 2 years ICD10 coding experience Utilization Management Experience Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills Experience with Outpatient Nursing (i.e. Durable Medical Equipment, Home Care, Physical Therapy, Occupational Therapy, Speech Therapy) Must have knowledge of medical management process and ability to interpret and apply member benefits as it relates to the contract. Must be able to problem solve in a fast paced environment, multitask, and meet tight deadlines Ability to perform detailed work with a high degree of accuracy Preferred: MedNet experience Prior managed care experience strongly preferred Understanding of regulatory standards and WTC contract requirements Knowledge of analyzing and reporting statistical data a plus Careers with LHI. Our focus is simple. We're innovators in cost-effective health care management. And when you join our team, you'll be a partner in impacting the lives of our customers, and employees. We've joined OptumHealth, part of the UnitedHealth Group family of companies, and our mission is to help the health system work better for everyone. We're located on the banks of the beautiful Mississippi River in La Crosse, Wis., with a satellite office in Chicago and remote employees throughout the United States. We're supported by a national network of more than 25,000 medical and dental providers. Simply put, together we work toward a healthier tomorrow for everyone. Our team members are selected for their dedication and mission-driven focus. For you, that means one incredible team and a singular opportunity to do your life's best work. SM 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.

Keywords: UnitedHealth Group, La Crosse , Utilization Management Registered Nurse, Healthcare , La Crosse, Wisconsin

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