Utilization Management Nurse RN - Remote

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives?

Join us to start Caring. Connecting. Growing together.

The Utilization Management Nurse RN, utilizing critical thinking skills and their clinical background, is responsible for reviewing clinical information from patient electronic medical records requested by our clients. They will coordinate key clinical findings, will run the clinical through agreed upon screening tool and will propose an initial case recommendation based on criteria outcome, supporting the clinical stay and/or supporting a case.

The nurse will also handle payor communications as appropriate.

The nurse will check the accuracy and thoroughness of their work prior to sending the case to our clients. The nurse will maintain quality and productivity expectations. The nurse will provide frontline customer service to clients and work in collaboration with other departments to ensure continuity of client care and satisfaction.

Schedule: Flexible in what they can cover - Operation is 8 AM - 8 PM - Every other weekend and rotating holidays.

You’ll enjoy the flexibility to work remotely
* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• The First Level Review Nurse will accurately and efficiently review case details from patient records focusing on key elements according to process and follow the agreed upon screening tools. The nurse will complete their case within the time expectations and provide high quality reviews. The First Level Review Nurse will perform their job functions, adhering to Optum Physician Advisor Solutions policies and procedures, which include but are not limited to the following
• Arrive to work on time and comply with time off expectations
  • Will adhere to company policies and procedures regarding scheduled arrival and break times as well as Holiday commitments and time off expectations
  • Will maintain an accurate account of time off in Verint and HR Direct as per policy guidelines
  • Will submit time off requests, temporary schedule changes, schedule adjustments, and/or report any scheduling discrepancies/errors per policy and procedure guidelines
• The First Level Review Nurse will work in OPAS clinical database/clinical data entry or directly in the client's database
  • Will enter clinical information into the company's/client's database as defined by the company policies and procedures
  • Will maintain proficient knowledge of the database and/or programs utilized by the First Level Team and other departments as needed
  • Will promptly report any issues with the database and/or programs utilized by the First Level Team to IT and to the supervisory staff as needed
• Review the inpatient clinical chart of patients in their assigned hospitals daily to assess the appropriateness of admission and ongoing medical care
• Apply clinical criteria and guidelines to ensure appropriate admission based on the use of relevant Inter Qual or MCG criteria and Medicare regulations and guidelines as appropriate
• Refer to Physician Advisors at Optum when cases do not meet clinical criteria guidelines and require second level review as appropriate
• Communicate clearly and effectively to client/provider/payer and internal Optum staff pertinent patient information to facilitate timely processing of cases and adhere to departmental turnaround times
• Work with Optum employees to identify patient utilization trends to assist clients to better assess their clinical care needs
• Complete data entry of admissions in the medical management systems, Review Manager or Indicia, daily including accurate patient demographics, working diagnosis, and clinical information
• Assist in resolving conflicts or issues between clients and Optum and have a clear understanding of when a situation needs to be escalated to a supervisor…