Position is responsible for utilization management, utilization review, or concurrent review (telephonic inpatient care management). Performs reviews of current inpatient services. Determines medical appropriateness of inpatient services following evaluation of medical guidelines and benefit determination.
Want to learn more before applying for this role? Click here to view the Realistic Job Preview: UHC_Telephonic_UM_Nurse.pdf
Utilization Management Nurse responsibilities include:
- Perform utilization and concurrent review using Milliman criteria
- Conduct clinical chart assessments
- Discuss cases with treating physicians and other healthcare professionals to better understand plans-of-care
- Identify and evaluate delays in care
- Initiate a discharge planning and readmission prevention plan when applicable
- Approve bed days for inpatient cases when applicable
- Arrange alternative care services; Contact and maintain communication with acute long term care, acute rehabilitation, or skilled nursing facilities to move patients through the care continuum
- Gather clinical information to assess and expedite care needs
- Maintain appropriate documentation
- Consult with the Medical Director as needed to troubleshoot difficult or complex cases
- Participate in telephonic and in-person staff meetings
UnitedHealthcare, part of the UnitedHealth Group family of companies, is comprised of three specialized businesses dedicated to meeting the health care benefits needs of individuals and groups; all part of something greater, but each with a specialized focus:
UnitedHealthcare Employer & Individual works with individuals, small businesses and large multi-site employers to provide innovative, affordable benefits services.
UnitedHealthcare Medicare & Retirement is focused on serving Americans over the age of 50. It is the largest business dedicated to meeting the growing health and well-being needs of aging individuals in the nation, serving one in five Medicare beneficiaries through a comprehensive and diversified array of products and services through four industry-leading businesses.
UnitedHealthcare Community & State provides high-quality, personalized, public-sector health care programs that help local government agencies improve health outcomes for millions of children and low-income and disabled individuals at an affordable cost.
Together, weâ€™re removing the barriers that keep people from receiving the kind of quality health care that makes a difference. We focus on Integrity, Compassion, Relationships, Innovation and Performance as we empower people to achieve better health and well-being.
Come grow and thrive in our culture of innovation and ideas. Because there is no opportunity greater than the quest to help people live healthier lives.
- A current, unrestricted RN license in state of residence
- Minimum of 3 years experience recent clinical experience
- Proficient with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment
- Experience in discharge planning and/or chart review is desired
- A background that involves utilization review for an insurance company or in a managed care environment is desired
- Familiarity with Milliman criteria guidelines would be helpful
- Case management certification and/or experience is preferred
- Ability to build and maintain relationships will be essential
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing
When you work to better people’s lives, one of those lives will always be yours.
We have modest goals: Improve the lives of...