Inpatient Utilization Management Nurse RN ̵...
2352383 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. The Utilization Review Nurse, RN is responsible for providing clinically efficient and effective Inpatient utilization management. Reviews inpatient criteria for acute hospital admissions and concurrent review and or prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all inpatient admission and preauthorization requests from providers that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service or treatment for review with the Medical Director for a decision. Required hours are 8am-5pm in PST or MST to include one weekend day, either Sunday-Thursday or Tuesday-Saturday, after the 3-6 month training period. Training for the first 3-6 months (or potentially longer depending on training progress) will be Monday-Friday 8am-5pm PST before moving to your regular schedule. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities:
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