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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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Positions in this family require a current, unrestricted nursing license (i.e. RN)

Positions in this function require various nurse licensure and certification based on role and grade level. Licensure includes RN or LPN/LVN, depending on grade level, with current unrestricted licensure in applicable state. LPN/LVN roles work under the direct supervision of an RN or MD. Function is responsible for performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

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

General Job Profile

• Provides leadership to and is accountable for the performance and direction through multiple layers of management and senior level professional staff
• Work most often impacts a large business unit, or multiple markets/sites

Primary Responsibilities:

• Develops and executes strategies for a function or discipline that span a large business unit or multiple markets/sites
• Directs others to resolve business problems that affect multiple functions or disciplines
• Product, service or process decisions are most likely to impact multiple functions and/or customer accounts (internal or external)

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:

• Bachelor’s degree in Nursing required, Master’s degree preferred
• Current unrestricted RN license in state of residence
• 5+ years of progressive leadership experience including leading operations and/or business process improvement initiatives, integrating the voice of internal and external constituents
• Health care industry experience
• Prior Authorization or Utilization Management experience
• Demonstrable entrepreneurial skills (accountable for risk from ideation to execution)
• Proven ability to drive a cross-functional team that produces value
• Proven solid leadership skills with proven ability to foster and manage senior-level relationships in a highly matrixed environment
• Proven high emotional intelligence
• Proven superior verbal and written communication skills
• Proven ability to influence with and without direct management/authority
• Proven superior customer/consultant relationship management and collaboration skills

Functional Competencies

Functional Competency & Description Proficiency Level

• CPS_Conduct Non-Clinical Research to Support Determinations E) Expert
  • Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial)
  • Validate that cases/requests for services require additional research
  • Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources)
  • Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
  • Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
• CPS_Review Existing Clinical Documentation E) Expert
  • Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) -Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
  • Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs)
  • Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
  • Apply understanding of medical terminology and disease processes to interpret medical/clinical records
  • Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
  • Review care coordinator assessments and clinical notes, as appropriate
• CPS_Conduct Clinical Research to Support Determinations E) Expert
  • Identify relevant information needed to make medical or clinical determinations
  • Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical policies, Coverage Determination Guidelines [CDG], National Comprehensive Cancer Network [NCCN], state/federal mandates) -Review/interpret other sources of clinical/medical information to support clinical or medical determinations (e.g., previous diagnoses, authorizations/denials, case management documentation)
  • Obtain information from patients, providers and/or care coordinators as needed to verify services rendered and/or recommend additional options (e.g., Organization Determination Appeals and Grievance [ODAG], steerage calls)
  • Apply knowledge of applicable state/federal mandates, benefit language, medical/ reimbursement policies and consideration of relevant clinical information to support determinations
  • Collaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e.g., Medical Directors and their staff, Optum, UHC, Account Management)
• CPS_Make Final Determinations Based on Clinical and Departmental Guidelines E) Expert
  • Demonstrate understanding of business implications of clinical decisions to drive high quality of care
  • Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS, NCQA/URAC accreditation)
  • Ask critical questions to ensure member- and customer-centric approach to work
  • Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
  • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
  • Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes
  • Use appropriate business metrics to optimize decisions and clinical outcomes
  • Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up)
• CPS_Achieve and Maintain Established Productivity and Quality Goals E) Expert
  • Meet/exceed established productivity goals
  • Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations -Manage/prioritize workload and adjust priorities to meet quality and productivity goals
• CPS_Drive Effective Clinical Decisions Within a Business Environment E) Expert
  • Ask critical questions to ensure member/customer centric approach to work
  • Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as needed
  • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
  • Identify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performance
  • Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, healthcare reform, URAC/NCQA/ERISA/state accreditation)

Values Based Competencies

Leader

• Integrity Value: Model and Ensure Ethical Behavior
  • Comply with Applicable Laws, Regulations and Policies
  • Demonstrate Integrity
  • Require Integrity and Ethical Behavior from Others
• Compassion Value: Deliver Value to Customers
  • Maximize Customer Growth and Retention
  • Optimize the Customer Experience
• Relationships Value: Lead and Develop People
  • Bring in the Right Talent
  • Develop People
  • Drive Employee Engagement
  • Foster Teamwork and Collaboration
  • Learn and Develop Self
  • Leverage Diversity and Inclusion
• Relationships Value: Communicate Effectively
  • Communicate with Impact
  • Influence and Negotiate
  • Listen Actively
  • Present Effectively
• Innovation Value: Lead Change and Innovation
  • Demonstrate Emotional Resilience
  • Implement Innovative Solutions
  • Manage Change
• Performance Value: Drive Sound, Disciplined Decisions
  • Apply Financial Knowledge
  • Make Decisions to Drive Action
• Performance Value: Drive High-Quality Execution
  • Communicate Clear Direction
  • Drive Operational Excellence
  • Manage Execution

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

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington or Washington, D.C. Residents Only: The salary range for this role is $122,100 to $234,700 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.

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.