Utilization Management Nurse RN

About Optum

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.

You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities of a Utilization Management Nurse RN

• Support and promote Optum and Bassett Healthcare Network goals and mission
• Onsite presence as needed to build relationships across Optum and the Bassett Healthcare Network
• Collaborate with peers in Medical Management, Case Management, RCM, Compliance, and Quality Management to assure continuity of communication and care
• Work in Epic and Case Advisor as well as Tiger Connect/phone providers
• Maintain proficient knowledge of the database and/or programs utilized by Optum and Bassett Healthcare Network
• Promptly report any issues with the database and/or programs
• Review patient records daily to assess appropriateness of admission and ongoing medical care
• 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
• 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
• Monitor patient status in Epic and in Case Advisor, escalating patient records that require a discussion on status
• Address Code 44 cases with Onsite Physician Advisor, Attending Physician and Case Manager timely
• 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
• 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

Secondary Functions

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

Case Processing

• Accurately and efficiently review clinical data from the patient records focusing on key elements and obtain additional information as needed for case review completion
• Accurately complete cases according to guidance provided
• Verify the accuracy and thoroughness prior to completing reviews
• Maintain or exceed quality expectations
• Participate in productivity and quality review meetings upon request from their direct supervisor
• 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 of company policies and procedures
• Maintain a secure working environment following Optum and Bassett Healthcare Network security policies and procedures
• Perform other related duties, tasks, and processes as required by Nursing leadership

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

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

Required Qualifications

• Associate's Degree in Nursing (or higher)
• Current Registered Nurse licensure and obtain New York licensure
• 5+ years of experience in med/surg OR 3+ years in critical care experience
• 2+ years of Utilization Management experience
• Intermediate level of proficiency with strong typing skills in Microsoft applications specifically Microsoft Word and Excel

Preferred Qualifications

• Epic/EMR experience
• Pre-authorization experience
• Strong knowledge of clinical requirements for inpatient medical necessity hospitalizations
• Case Management experience
• Working knowledge of InterQual® and/or MCG Guidelines® with the ability to apply criteria consistently and accurately
• Certified Case Manager (CCM)

Soft Skills

• Demonstrates organization
• Professional attitude and team player, with ability to work independently
• Knowledge of insurance payer processes
• Ability to learn and understand various clinical software applications
• Strong written and verbal communication skills - able to convey key concepts clearly and succinctly
• Experience in fostering collegial relationships and partnerships amongst colleagues
• Demonstrates collaborative skills and ability to interact with people of different backgrounds and organizational levels, including clients
• Self-motivated and able to function in a fast-paced work environment
• Demonstrates the ability to stay focused on the detail
• Ability to use sound judgment, deductive reasoning, and problem-solving abilities with the ability to multi-task and prioritize work
• Ability to adapt to changes in priorities and can absorb changes in the work volume
• Meets and maintains quality and productivity standards

Key skills/competency

• Utilization Management
• Clinical Criteria Application
• Patient Record Review
• Epic EMR
• MCG Guidelines
• InterQual Criteria
• HIPAA Compliance
• Care Coordination
• Collaborative Communication
• Critical Thinking