Utilization Management LVN - Remote at UnitedHealth Group
About the position
For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. 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. Under the general direction of the Utilization Management Manager, you will be responsible for prospective and concurrent/retrospective review of referrals ensuring regulatory requirements are being met as they relate to language readability and appropriate citation of criteria in Member correspondence. You will also be responsible for ensuring Member's needs are met using nationally recognized UM criteria. You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.
Responsibilities
Responsible for screening and reviewing prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service and care and discussing with Medical Directors.
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Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources, and community resources.
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Responsible for the prospective review to determine the appropriateness of denial, possible alternative treatment, and draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language.
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Coordinate out-of-network and out-of-area cases with members' health plans and the Case Management team.
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Review patient referrals within the specified care management policy timeframe (Type and Timeline Policy).
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Develop and maintain effective working relationships with physicians and office staff.
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Demonstrate a thorough understanding of the cost consequences resulting from care management decisions through the utilization of appropriate reports such as Health Plan Eligibility and Benefits and Division of Responsibility (DOR).
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Maintain effective communication with health plans, physicians, hospitals, extended care facilities, patients, and families.
Requirements
Graduation from an accredited Licensed Vocational Nurse program.
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Active, unrestricted LVN license in the state of California.
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1+ years utilization management experience including prior authorization.
Nice-to-haves
3+ years of experience working as an LVN/LPN.
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2+ years of previous care management, utilization review or discharge planning experience.
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1+ years of clinical experience working as an LVN/LPN.
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Experience in an HMO or experience in a Managed Care setting.
Benefits
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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