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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)

Positions in this function is responsible for timely, accurate medical review, determining if requests for services to be provided to The Group patients meet criteria for coverage based upon medical policies, guidelines, and health plan criteria.  Responsible for review of inpatient length of stay for compliance with medical policies, guidelines, and health plan criteria. Based on criteria may refer cases to Medical Director Care Management for further review.  Ensures compliance to contractual and service standards as identified by relevant health insurance plans and The Group.  This is performed under the direct supervision of the Medical Director, Care Management. Adheres to policies, procedures and regulations to ensure compliance and patient safety.  Participation in Compliance and other important training is a condition of employment.

Primary Responsibilities:

• Provides timely, accurate review of precertification and prior authorization requests, for compliance with applicable medical policies and health plan benefits 
• Provides concurrent medical review of inpatient length of stays to ensure compliance with applicable medical policies and health plan benefits
• Providing both outpatient and inpatient medical management review as needed, to ensure that patient healthcare requirements and organizational goals are met in a reasonable and medically appropriate manner
• Ensure communication regarding medical reviews are provided to relevant patients and Providers in a timely manner, and in compliance with contractual agreements
• Ensures compliance with HIPAA and other applicable company policies and procedures as well as regulatory requirements
• Identify and address opportunities for quality improvement in all aspects of serving our customers.  Assist in planning and implementation of systems changes and procedures to achieve overall organizational objectives
• Maintain effective communication with management regarding development within areas of assigned responsibilities and performs special projects as required
• Travel to facilities to perform reviews (up to 25%)
• MCG certification within one year of hire
• Performs other duties as assigned

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:

• Associates degree in Nursing
• Valid, unrestricted, NM RN License or valid multi-state compact license. Must be 21 years or older and have a valid NM State Driver’s license
• 3+ years of job related experience in a healthcare environment
• PC proficient
• Ability to communicate and interact professionally with co-workers, management patients, and Providers
• Ability to counsel and/or consult
• Working knowledge of HMO’s, PPO’s, Medicare, Medicaid, and insurance plans
• Knowledge of CPT4/ICD 9 & 10/HCPCS codes
• Must pass a nationwide criminal history screen through the Caregivers Criminal History Screening Program
• Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifications:

• Bachelor’s degree in Nursing
• Certified Case Manager
• Utilization Review or Case Management Certificate
• 2+ years of experience providing case management and/or utilization review functions within health plan or integrated system

Physical Demands:

• Standing
• Sitting
• Walking
• Kneeling/Crouching
• Lifting

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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.