Utilization Review Nurse - Hybrid

Optum in the tri-state region (formerly CareMount Medical, ProHEALTH New York and Riverside Medical Group) offers an interconnected network that enables us to work collaboratively to better coordinate care among our doctors and care teams. Together, we offer you and your family access to more than 2,100 providers, representing 70 specialties, working in 360 medical practices and more than 55 urgent care locations across New York, New Jersey and Southern Connecticut.

We’re a dynamic and growing health care organization, offering a wide range of employment opportunities. We are seeking professional and dedicated individuals to be part of our team, where integrity, respect, accountability, and collaboration are among our core principles. Work with the largest care delivery organization in the world and start doing your life's best work.(sm)

If you are located in the state of New York, you will have the flexibility to remotely*, as well as work in the office as you take on some tough challenges.

Primary Responsibilities:

• Apply clinical criteria and guidelines to ensure appropriateness of admission based on the use of relevant MCG® criteria and Medicare regulations and guidelines as appropriate
• Monitor patient status in Epic and in Case Advisor, escalating patient records that require a discussion on status
• Work with the Utilization Management Nurse Manager to identify patient utilization trends to assist the Bassett Healthcare Network to better assess their clinical care needs
• Addresses Code 44 cases with Onsite Physician Advisor, Attending Physician and Case Manager timely
• Assist in resolving conflicts or issues with patient statuses and have a clear understanding of when a situation needs to be escalated to a supervisor and/or management for timely resolution
• Review patient records daily in order to assess appropriateness of admission and ongoing medical care
• Refer to Physician Advisors at Optum and/or at Bassett Healthcare Network when cases do not meet clinical criteria guidelines and require second level review as appropriate

Secondary Functions:

• Maintain strict patient confidentiality
• Maintain regular and acceptable attendance level as determined by the employer
• Assist and support the Director and Utilization Management Nurse Manager to maintain consistency and accuracy of the workflow processes of the team.
• Other duties as requested
• Ability to navigate electronic medical records
• Work in a manner that is not disruptive to peers, supervisors and/or subordinates
• Maintain availability and willingness to work such days and hours the employer determines are necessary or desirable to meet its business needs.
• Professional demeanor and the ability to work effectively within a team and/or independently
• Flexible with the ability to shift priorities when required

Case Processing

• Accurately complete cases according to guidance provided
• Assist with identification and correction of inaccurate and incomplete information
• Maintain a secure working environment following Optum and Bassett Healthcare Network security policies and procedures
• Work in collaboration with other departments
• Impart confidential information appropriately per HIPAA regulations and company requirements and will follow the HIPAA policies
  • Impart confidential information appropriately per HIPAA regulations and company requirements
  • Identify instances of potential HIPAA violations and notify the appropriate staff per company policies and procedures
  • Maintain a secure working environment following Optum and Bassett Healthcare Network security policies and procedures
• Interdepartmental collaboration
  • Work in collaboration with other departments
  • Assist with identification and correction of inaccurate and incomplete information
  • Submit potential HIPAA issues per policy
  • Assist other departments as the business needs dictate
  • Provide ongoing support to other department team members
• Assist other departments as the business needs dictate
• Provide ongoing support to other department team members
• Accurately and efficiently review clinical data from the patient records focusing on key elements and obtain additional information as needed for case review completion
• Remain up to date on competencies
• Verify the accuracy and thoroughness prior to completing reviews
• Complete MCG® trainings as directed
• Participate in productivity and quality review meetings upon request from their direct supervisor
• Participate in additional training and/or projects under the direction of Nursing leadership
• Complete E- Learning courses per policy
• Identify instances of potential HIPAA violations and notify the appropriate staff per company policies and procedures
• Submit potential HIPAA issues per policy
• Perform other related duties, tasks, and processes as required by Nursing leadership
• Impart confidential information appropriately per HIPAA regulations and company requirements
• Attend company, team, and individual meetings as directed
• Maintain or exceed quality expectations
  • Participate in productivity and quality review meetings upon request from their direct supervisor
• Education, Projects, and Meetings
  • Attend company, team, and individual meetings as directed
  • Remain up to date on competencies
  • Complete E- Learning courses per policy
  • Complete MCG® trainings as directed
  • Participate in additional training and/or projects under the direction of Nursing leadership

Location

• This position will require working onsite and/or working remotely in a private area

Hours

• Normal business hours and may need to work afterhours
• Monday through Friday primarily
• Telecommute as approved, onsite as needed
• Hours will be based on business needs of the company, including holidays and weekends
• Willing to work flexible hours as needed

Skills

• Working knowledge of InterQual® and/or MCG Guidelines® with the ability to apply criteria consistently and accurately
• Accept ownership and accountability for compliance with CMS and contracts
• Knowledge of insurance payer processes
• Ability to learn and understand various clinical software applications
• Knowledge with Medicare rules/regs/conditions of participation
• Epic/EMR experience
• Ability to use sound judgment, deductive reasoning, and problem-solving abilities with the ability to multi-task and prioritize work
• Demonstrates collaborative skills and ability to interact with people of different backgrounds and organizational levels, including clients
• Computer-proficient, with solid typing skills in Microsoft applications specifically Microsoft Word and Excel
• Demonstrates organization
• Solid knowledge of clinical requirements for inpatient medical necessity hospitalizations
• Professional attitude and team player, with ability to work independently
• Meets and maintains quality and productivity standards
• Excellent written and verbal communication skills - able to convey key concepts clearly and succinctly
• Self-motivated and able to function in a fast-paced work environment
• Ability to adapt to changes in priorities and can absorb changes in the work volume
• Experience in fostering collegial relationships and partnerships amongst colleagues
• Will work with Tiger Connect/phone with providers
• Demonstrates the ability to stay focused on the detail

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:

• This position will require working onsite and/or working remotely in a private area
• Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
• Experience working with clinical healthcare information systems
• Hours will be based on business needs of the company, including holidays and weekends
• 3 + years of med/surg and/or critical care experience
• Experience in Utilization Review/Management
• Willing to work flexible hours as needed
• Telecommute as approved, onsite as needed
• Current Registered Nurse licensure mandatory and obtain New York Licensure
• Normal business hours and may need to work after hours

Preferred Qualifications:

• 2+ years of case management and/or concurrent/utilization review experience
• Current working knowledge of InterQual® or MCG Guidelines®
• BSN, case management certification and discharge planning experience

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

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.

CareMount Medical, ProHEALTH Care Associates, and Riverside Medical Group (the “Practices”) are all physician owned and led practices having complete authority for all medical decision-making and patient care through their physicians and other licensed professionals. Optum, through its management organizations (“Optum”) provides non-clinical administrative services to support the Practices and their physicians. Neither Optum nor its management companies employs, engages, or supervises physicians or other licensed professionals, or determines or sets the methods, standards, or conduct of the practice of medicine or health care provided by the Practices or by any of their licensed professionals. “Part of Optum” reflects that the Practices are part of Optum’s effort to support forward-thinking physician practices in helping their patients live healthier lives.

New York Residents Only: The salary range for New York residents is $56,300 to $110,400. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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.

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

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: 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.