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Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.
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As an RN, Unitarization Managment, you will be 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 compliant denial notices.
Primary Responsibilities:
- Consistently exhibit behavior and communication skills demonstrating Optum's commitment to superior customer service, including quality, care, and concern with every internal and external customer
- Perform all functions of a UM nurse reviewer
- Compose denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards
- Construct denial notices to ensure the intended recipients understand the rationale for the denial of service and are specific to the member's condition and request
- Ensure the denial reason is in the appropriate grade level and is easily understandable
- Ensure the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria, or protocols based on the type of denial
- Select the correct hierarchy level and apply it correctly based on the available medical information
- Provide relevant clinical information to the request and the criteria used for decision-making
- Ensure that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria applied
- Evaluate out-of-network and tertiary denials for accessibility within the network
- Perform a quality assurance audit on each denial before finalization to ensure all elements comply with established guidelines
- Consult with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination
- Escalate non-compliance cases to UM compliance and consistently report on denial activities
- Collaborate with UM compliance for continued quality improvement efforts for adverse determinations
- Identify gaps in training or process impacting the overall compliance of adverse determinations and communicate an effective performance improvement solution in writing
- Meets or exceeds productivity targets
- Uses, protects, and discloses Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
- Performs additional duties as assigned
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:
- Graduation from an accredited school of nursing
- Active, unrestricted Registered Nurse license through the State of California
- 3+ years of care management, utilization review or discharge planning experience
Preferred Qualifications:
- Bachelor of Science in Nursing, BSN
- HMO experience
California Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. 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.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.