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. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Utilization Management Nurse will accurately and efficiently review and extract pertinent case details from patient medical records; and craft strongly defensible appeal letters per process instructions and the department's/company's guidance. The nurse will complete their case within the time expectations while providing high quality reviews. The Utilization Management Nurse will perform their job functions, adhering to both Optum and OPAS policies and procedures, which include but are not limited to the following Schedule: Monday - Friday (40 Hours a Week) Flexible start times with the ability to support evening, weekend and holiday shifts. You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Follows directive of composing appeal letters to include appropriate data extraction, construction of well-written appeals letters with proper grammar, utilization of appeal tools including pre-constructed templates, inclusion of appropriate medical literature references, and use of national criteria guidelines. Adheres to company policies and procedures as well as policies, procedures, and laws Understands and complies with HIPAA confidentiality requirements Support and promote OPAS, Optum, and the enterprise goals and mission Build relationships across Optum, OPAS, OGA and our clients Collaborate with peers to assure continuity of communication and execution of deliverables as needed Adheres to quality and productivity expectations Participate in and contribute to meetings as appropriate Maintains organization on the team and ensures everyone conducts themselves professionally Remains up to date with all learning modules, competencies, and state required licenses Performs other related duties, tasks, and processes as required by leadership Ability to establish priorities, be self-motivated, work independently, and follow instructions with supervision and structure Positive attitude and the ability to function as a collaborative team member 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: Associate's degree Unrestricted Registered Nurse license in your state of residence 3+ years of bedside nursing experience in adult ED/telemetry/ICU/CCU Advanced level of proficiency with Microsoft applications and software, internet navigation and utilization Ability to type 45 wpm Preferred Qualifications: Working knowledge of InterQual and MCG Prior experience with utilization management Working knowledge of Word Strong, effective verbal and written communication skills *All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 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. #RPO, #GREEN
Description Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? Summary: The Clinical Documentation Review Specialist is responsible for collaborating with clinicians to assure accurate completion of documentation and development of effective plans of care to assure appropriate utilization and promote appropriate quality patient care and positive patient outcomes. Responsibilities: Documentation Improvement: Reviews clinical documentation for compliance with state, federal, and TJC regulations. Follows up with team for clarification if documentation is unclear. Identifies and documents delays. Collaborates with clinicians to assure accurate completion of documentation and development of effective plans of care. Elevates issues appropriately. Utilization Management: Collects and submits data as indicated. Quality Improvement and Risk Management: Reviews clinical reports for compliance with state, federal, and TJC regulations. Collects and submits data as indicated. Communicates with service line and clinical effectiveness team members. Works with department leadership to develop and implement solutions to issues identified. Credentials: RN (Required) Must have Pennsylvania RN Education or Equivalent Experience: Bachelor of Arts or Science (Required) Education Specialization: Must have BSN from an accredited school of nursing Equivalent Experience: •And 2+ years In Medicare regulations for OASIS, compliance, and coding and/or experience in home care criteria and processes. We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
