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For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. 

Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

Under the general direction of the Utilization Management Manager, the Utilization Management Nurse is responsible for prospective and concurrent/retrospective review of referrals ensuring regulatory requirements are being met as they relate to language readability and appropriate citation of criteria in Member correspondence. This position is responsible for ensuring Member’s needs are met using nationally recognized UM criteria.

If you are located in Southern CA, you will have the flexibility to work remotely* as you take on some tough challenges. 

Primary Responsibilities:

• Review referrals and authorizations following established policies and procedures in accordance with nationally recognized standards
• Ensure referrals are reviewed and processed within required timeliness standards
• Process referrals using online system, evidence based guidelines and criteria hierarchy from CMS and health plans
• Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources and community resources
• Develop and maintain effective working relationships, with physicians and office staff
• Coordinate out-of-network and out-of-area cases with member, health plans and Case Management team
• When unable to approve a requested service, recommend alternative health care services utilizing contracted, community and internal services/programs
• Maintain comprehensive and confidential authorization documentation
• Utilize clinical knowledge to apply any/all evidence-based practice guidelines and criteria
• Maintain confidentiality of all member information and company business
• Present as a professional representative of the organization
• Perform additional duties/tasks as assigned by Supervisors, Manager and Director
• Comply with all departmental and company policies and procedures
• Attend in-services, training and meetings relating to job tasks as directed and required
• Maintain regular and consistent attendance

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. 

Years of post-high school education can be substituted/is equivalent to years of experience

Required Qualifications: 

• Graduation from an accredited Licensed Vocational Nurse program
• Active, unrestricted LVN license in the state of California 
• 1+ years of clinical experience working as an LVN/LPN
• 1+ years Utilization management experience including Prior Authorization

Preferred Qualifications: 

• 3+ years of experience working as an LVN/LPN
• 2+ years of previous care management, utilization review or discharge planning experience
• Experience in an HMO or experience in a Managed Care setting

California Residents Only: The hourly range for California residents is $18.80 to $36.78 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives. 

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

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: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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. 

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment