The Utilization Review Nurse conducts independent review, research and analysis of requests for services to determine medical necessity appropriateness including the appropriate levels of care with concentration on prudent standards of best practice and clinical decision sets, directed discharge planning with attention to planned, referrals to Case Management to maximize quality clinical outcomes while managing medical costs. Adherence to Health Plan benefits and Medicare Guidelines is required. Outstanding critical thinking and customer service skills, problem solving ability, prioritization and organizational skills are required.
Preauthorization and concurrent utilization review of requests from providers per the department policies and procedures observing NCQA and CMS practices.
Devising, documenting and communicating appropriate discharge planning efforts to facilitate the member receiving the appropriate care in the appropriate setting.
Update and maintain UM documentation system for pertinent medical necessity review findings, as well as determinations and applicable confinement and service authorization screens. Documentation must follow the Health Plan policies and procedure.
Interface with internal Medical Director(s), as well as external physician review vendors for final determinations on adverse reviews.
Interdepartmental collaboration with the Appeals and Claims departments as needed, including facilitation of appropriate release of claims reimbursement.
Provide oversight to UM Intake Associate or UM Intake Nurse Coordinator for the purpose of appropriate identification, routing and resolution of concurrent review requests.
Coordinate with the interdisciplinary care team in making a safe discharge plan and make appropriate new referrals for additional care coordination, such as Case Management, Social Work.
Correspond with facilities, members and providers for clinical information and details of review request, when warranted, as well as, for the provision of a final determination for a prospective or concurrent medical necessity review.
Demonstrates knowledge and understanding of the laws, regulations and policies that pertain to the organizational unitâ€™s business and conforms to these laws, regulations, and policies in carrying out the accountabilities of the job.
A current, unrestricted RN license in state of residence
Minimum of 2 + years experience working in utilization or case management in a managed care environment
Basic level of experience with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment
Minimum of 2 + years of experience in the acute inpatient setting
Experience in acute long term care, acute rehabilitation, or skilled nursing facilities is desired
A background that involves utilization review for an insurance company or in a managed care environment is desired
Ability to build and maintain relationships will be essential
A Bachelors degree is preferred
Imagine joining a group of professionals and clinicians who are working to improve health care for people over 50. Consider the influence you can have on the quality of care for millions of people. Now, enhance that success with enthusiasm you can really feel.
That's how it is at UnitedHealthcare Medicare & Retirement. Everyday, we're collaborating to improve the health and well being of the fastest growing segment of our nation's population. And we're doing it with an intense amount of dedication.
Here, you will discover a culture that grows through challenge. That evolves by being flexible. That succeeds by staying true to our mission to make health care work effectively and efficiently for seniors. Put your best to work for us, and discover extraordinary opportunities for growth.
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.
Key Words: Nurse, Nursing, RN, Registered Nurse, Utilization Review, Utilization Management, Case Management, Medical Necessity Review, Baltimore, MD, Maryland
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