RN Case Manager, Utilization - Colorado Telecommute

Careers at UnitedHealth Group

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Compassion. It's the starting point for health care providers like you and it's what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you're also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life's best work. SM

Our teams are helping people from around the world. We can bring out your best as you put your listening, analytical and problem solving skills to work in a setting that is geared to helping improve lives and enhance health care for millions. Here, you'll discover a wealth of pathways for professional growth within Customer Service, Billing, Claims, Enrollment & Eligibility and across our global economy. Join us and find out why this is the place to do your life's best work. SM

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

The RN Case Manager provides utilization management services, in coordination with other Case Management staff, using pre-established guidelines and criteria to perform review activities in order to assure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third party payors. In a pro-active manner, the UR RN will provide the necessary medical information to justify the medical necessity of the hospital stay and will take necessary follow-up action to assist in the appeal processes of denials

If you are located in Colorado, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:
  • Adheres to name badge/dress code compliance
  • Effectively problem-solves and actively pursues resolution
  • Directly communicates with staff, physicians, patients and families
  • Role models leadership behavior through courtesy, respect and efficiency

Utilization Management
  • Assesses all new inpatient admissions for identification of status and admission necessity and makes initial pro-active UR contact with appropriate Payor
  • Daily assess the continuity of care in conjunction with the Case Managers and Social Workers in regards to the continued medical necessity of hospitalization and the status of the discharge plan, and communicates this to the Third-Party Payor
  • Coordinates with other Case Management staff to help identify and control inappropriate resource utilization
  • Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria. Review calls are returned on the same day when possible, and no later than the next business day
  • Without direct supervision, utilizing time constructively and organizing assignments for maximum productivity
  • Utilizes information provided by the Financial Counselors/Admissions regarding authorized length of stay and follows up with third-party payors on an ongoing basis, and documents in Bar the communications regarding continued authorizations
  • Follows up on denials communicated to the department and works with the Patient Accounting staff to assist with appeals
  • Administers denial of stay letters to patients as indicated
  • Maintains and demonstrates appropriate clinical knowledge in order to assist physicians in providing documentation of severity of illness and intensity of service in order to assure that criteria for acute hospitalization are met
  • Is familiar with Employees are expected to comply with all regulatory requirements, including Joint Commission Standards
  • Is familiar with organization, department and job specific Environment of Care areas, including Life Safety, Utilities Management, Hazardous Materials Communications, Emergency Preparedness, Infection Control and Medical Equipment Failure
  • Adheres to Standard Precautions as appropriate, which may include:
    • the use of protective barriers, as appropriate (e.g., gloves, masks, gowns, pocket masks, and/or safety glasses);
    • handling and disposing of infectious waste appropriately; and
    • hand washing as appropriate

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.

Required Qualifications:

  • Current Colorado RN license in good standing
  • 2+ years required recent Utilization Review experience in a hospital or with a Third-Party Payor
  • If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking order

Preferred Qualifications:
  • 3+ years recent Utilization Review experience in a hospital or with a Third-Party Payor
  • BSN

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

Colorado Residents Only: The salary range for Colorado residents is $53,300 to $95,100. Pay is based on several factors including but not limited to education, work experience, certifications, etc. As of the date of this posting, In addition to your salary, UHG offers the following benefits for this position, subject to applicable eligibility requirements: Health, dental, and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term disability insurance, and long-term disability insurance; business travel accident insurance; Employee Assistance Program; PTO; and employee-paid critical illness and accident insurance.

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Colorado, Telecommuter, Telecommute, Remote, Work from home, Utilization Review, RN, Registered Nurse