Remote Utilization Review RN, Optum

About the position 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 diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. As an Inpatient Care Management Nurse, you will be responsible for ensuring proper utilization of our health services. This means you will be tasked with assessing and interpreting member needs and identifying solutions that will help our members live healthier lives. This is an inspiring job at a truly inspired organization. You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. In this full-time position, you will work 40 hours a week, Monday through Friday, with hours between 8:00 AM and 5:00 PM. Your primary responsibilities will include performing initial and concurrent reviews of inpatient cases applying evidenced-based criteria (InterQual criteria), discussing cases with facility healthcare professionals to obtain plans-of-care, and collaborating with Optum Enterprise Clinical Services Medical Directors on performing utilization management. You will also participate in discussions with the Clinical Services team to improve the progression of care to the most appropriate level, consult with the Medical Director for complex cases, and apply clinical expertise when discussing cases with internal and external Case Managers and Physicians. Additionally, you will identify delays in care or services and manage them with the Medical Director, facilitate timely and appropriate care and effective discharge planning, and maintain compliance with Federal, State, and accreditation organizations. You will also identify opportunities for improved communication or processes and participate in audit activities and meetings. 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.

Responsibilities

• Perform initial and concurrent review of inpatient cases applying evidenced-based criteria (InterQual criteria)

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• Discuss cases with facility healthcare professionals to obtain plans-of-care

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• Collaborate with Optum Enterprise Clinical Services Medical Directors on performing utilization management

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• Participate in discussions with the Clinical Services team to improve the progression of care to the most appropriate level

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• Consult with the Medical Director, as needed, for complex cases and make appropriate referrals to downstream partners

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• Apply clinical expertise when discussing cases with internal and external Case Managers and Physicians

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• Identify delays in care or services and manage with MD

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• Follow all Standard Operating Procedures in end to end management of cases

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• Facilitate timely and appropriate care and effective discharge planning

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• Participate in team meetings, education, discussions, and related activities

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• Maintain compliance with Federal, State and accreditation organizations

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• Identify opportunities for improved communication or processes

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• Participate in audit activities and meetings

Requirements

• Current, unrestricted RN license in the state of residence

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• 3+ years of acute care clinical nursing experience

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• 1+ years of utilization review experience using evidence-based guidelines

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• Demonstrate a proficiency in computer skills - Windows, Teams, Excel (Microsoft Suite), Outlook, clinical platforms

Nice-to-haves

• Bachelor's degree / BSN

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• Compact nursing license

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• Managed Care experience

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• Experience performing discharge planning

Benefits

• 401(k) matching

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• comprehensive benefits package

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• incentive and recognition programs

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• equity stock purchase

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• 401k contribution

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