Acute Utilization Review RN

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.

Positions in this function is responsible for timely, accurate medical review, determining if requests for services to be provided to The Group patients meet criteria for coverage based upon medical policies, guidelines, and health plan criteria. Responsible for review of inpatient length of stay for compliance with medical policies, guidelines, and health plan criteria. Based on criteria may refer cases to Medical Director Care Management for further review. Ensures compliance to contractual and service standards as identified by relevant health insurance plans and The Group.

This is performed under the direct supervision of the Medical Director, Care Management. Adheres to policies, procedures and regulations to ensure compliance and patient safety. Participation in Compliance and other important training is a condition of employment.

• Provides timely, accurate review of precertification and prior authorization requests, for compliance with applicable medical policies and health plan benefits
• Provides concurrent medical review of inpatient length of stays to ensure compliance with applicable medical policies and health plan benefits
• Providing both outpatient and inpatient medical management review as needed, to ensure that patient healthcare requirements and organizational goals are met in a reasonable and medically appropriate manner
• Ensure communication regarding medical reviews are provided to relevant patients and Providers in a timely manner, and in compliance with contractual agreements
• Ensures compliance with HIPAA and other applicable company policies and procedures as well as regulatory requirements
• Identify and address opportunities for quality improvement in all aspects of serving our customers. Assist in planning and implementation of systems changes and procedures to achieve overall organizational objectives
• Maintain effective communication with management regarding development within areas of assigned responsibilities and performs special projects as required
• MCG certification within one year of hire
• Performs other duties as assigned

• Licensed in state of residency
• 3+ years of job-related experience in a healthcare environment
• Working knowledge of HMO's, PPO's, Medicare, Medicaid, and insurance plans
• Knowledge of CPT4/ICD 9 & 10/HCPCS codes
• PC proficient
• Demonstrated ability to communicate and interact professionally with co-workers, management patients, and Providers
• Demonstrated ability to counsel and/or consult
• Must pass a nationwide criminal history screen through the Caregivers Criminal History Screening Program
• Weekend availability

• Bachelor's degree in Nursing
• Utilization Review or Case Management Certificate
• 2+ years of experience providing case management and/or utilization review functions within health plan or integrated system