LTSS Utilization Management, RN - Remote in NM
About the position
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Senior Utilization Management Nurse will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for complex and/or critical issues. This position will communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding; and will provide summary clinical and ancillary information to the Health Plan Medical Director for review and decision making. If you are located in New Mexico, you will have the flexibility to work remotely as you take on some tough challenges.
Responsibilities
Responsible for utilization management of LTSS determinations and oversight on outpatient service requests from a reporting perspective.
,
Leverage experience and understanding of disease pathology to review chart/clinical information and identify appropriate course of care.
,
Determine medical appropriateness using medical guidelines and benefit determination.
,
Solve complex problems and develop innovative solutions.
,
Oversee and run biweekly meetings for Complex/High Risk members in conjunction with LTSS and Health Services staff.
,
Review work performed by others and provide recommendations for improvement, including performing annual IRR for LTSS determinations.
,
Provide explanations and information to others on the most complex issues.
,
Leverage appropriate clinical terminology when communicating with physicians and other medical professionals.
,
Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action.
,
Apply professional judgment, take initiative to follow up, and manage conversations to make sound conclusions/recommendations regarding LTSS patient care or coverage.
,
Prepare reports as directed.
Requirements
Current, unrestricted independent licensure as a New Mexico Registered Nurse
,
3+ years of clinical experience
,
1+ years of Utilization Management experience
,
1+ years of experience with MS Office, including Word, Excel, and Outlook
,
1+ year of experience in HCBS LTSS Care Coordination and LTSS UM Determination
,
Background in Managed Care
,
Currently reside in New Mexico
,
Ability to travel locally up to 10% of the time
,
Ability to adhere to a Monday - Friday 8a - 5p MST work schedule
Nice-to-haves
Master's degree or higher in clinical field
,
InterQual Certified and/or Milliman (MCG) Certified
,
MIDAS experience
,
Proficient in ICUE and Community Care
Benefits
Flexible work arrangements
,
Opportunities for professional development
,
Recognition for performance
,
Supportive work environment
Apply Job!