or 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, you will be 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. You will also be responsible for ensuring Member's needs are met using nationally recognized UM criteria. If you are located in San Diego, CA, you will have the flexibility to work from home and in the office in this hybrid role* as you take on some tough challenges.
Primary Responsibilities:
Responsible for screening and reviewing prospective, concurrent, and retrospective referrals and authorizations for medical necessity and appropriateness of service and care and discussing with Medical Directors Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources, and community resources Responsible for the prospective review to determine the appropriateness of denial, possible alternative treatment, and draft denial language to ensure consistent application of standardized, nationally recognized UM criteria and appropriate use of denial language Coordinate out-of-network and out-of-area cases with members' health plans and the Case Management team Review patient referrals within the specified care management policy timeframe (Type and Timeline Policy) Develop and maintains effective working relationships with physicians and office staff Demonstrate a thorough understands of the cost consequences resulting from care management decisions through the utilization of appropriate reports such as Health Plan Eligibility and Benefits and Division of Responsibility (DOR) Maintain effective communication with health plans, physicians, hospitals, extended care facilities, patients, and families 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.
Qualifications: External
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/LPN1+ years Utilization Management experience including Prior Authorization
Preferred Qualifications:
3+ years of experience working as an LVN/LPN2+ 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 this role is $19.47 to $38.08 per hour. 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. 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.
