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.

The Case Manager (CM) / Utilization Review (UR) nurse staff augmentation full time role will temporarily fill in for Optum care management teams for short term staffing as well as provide consultative support to the front-line care management team, as appropriate. During each assignment, the role will provide comprehensive care management or utilization review services in various locations.

This is a 100% travel position with ability to go home every other weekend

Primary Responsibilities:

• Case Manager (CM)

• Coordination of patient services through an interdisciplinary process, which provides a clinical and psychosocial approach through the continuum of care

• Through case management, patients will be assessed to determine appropriateness of admission, continued hospitalization, as well as appropriate level of care

• Case Managers facilitate timely care delivery at the right time and in the right setting, escalate operational barriers, and collaborate with all stakeholders

• Discharge planning will begin at the time of (or prior to) admission and will be reassessed ongoing throughout the course of hospitalization in partnership with the clinical care team, the patient, and/or the patient’s representative. Quality and Risk Management issues will also be monitored for and reported as appropriate

• Continuum of Care Planning

• Responsible for integrating the assessment of the need for post-hospital services and determination of an appropriate discharge plan for complex cases

• Educates patient/family as to options/choices within the level of care determined to be appropriate. Initiates and insures completion of all necessary paperwork

• Facilitates completion of orders as required prior to transfer of patient to the next level of care in a timely manner so discharge is not delayed

• Continuum of Care planning will emphasize education and collaboration with physicians, family members, clinical social workers, nursing staff, therapists, and case managers from contracted payors when appropriate to determine discharge plan that will be of maximum benefit to the patient. Involves staff from next level of care in the treatment plan as early as possible to promote continuity and collaboration

• Utilization Review Nurse

• Provides utilization management services, in coordination with other Case Management staff, providers, and other healthcare team members, using pre-established guidelines and criteria to perform review activities to assure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors

• Proactively provide necessary medical information to justify the medical necessity of the hospital stay and will take necessary follow-up action to assist in the appeal processes of denials

• Has knowledge of all applicable federal and state regulations. Demonstrates a working knowledge of managed care and Medicare health plans as well as reimbursement related to post-acute services within the continuum of care

• Consults with physician section leaders for support in cases that continued stay is not appropriate and case manager is unable to come to resolution by working with assigned physician

• Communicating with the department director length of stay (LOS) and financial information, as well as issues that may affect the continuum of care process

• Engages attending physicians or ED physicians as appropriate if clinical information is incomplete or needs clarification

• Consultative Services:

• Provide consulting services in care management redesign with the frontline team members. This individual will work alongside client teams to solve complex business problems, improve performance, and execute high priority initiatives by conducting and/or interpreting analyses, creating deliverables, and helping drive project execution for Optum’s transformational clients

• Supports front line redesign for care management transformation in conjunction with operations and transformational leaders and team

• Synthesizes findings and summarizes a broad range of data inputs into outputs that clearly communicate data findings and insights

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:

• 3+ years of experience in an Acute Care Hospital performing discharge planning as a Case Manager

• 3+ years of Utilization Management experience in a hospital or with a Third-Party Payor

• Experience with Inpatient care, in Acute Care Hospital

• Knowledge of Utilization Review, Medicare Requirements processes, as well as State and Federal regulations pertaining to Utilization Review and Discharge Planning

• Knowledge/understanding of InterQual and/or MCG criteria of medical necessity

• Proven ability to compile, evaluate, and report statistics to members of the team as well as to utilize this information to facilitate process improvement activities

• Proven ability to compile, evaluate, and present clinical information to justify hospitalization to outside Third-Party Payors

• Ability to travel 100%

Preferred Qualifications:

• Case Management Certification

• Basic Life Support certification

• Certification in CCM (certified case manager), ACM (Accredited Case Manager), MCG, and/or InterQual

• Traveler experience

• MSN

• Clinical knowledge of the Labor and Delivery, Neonatal, Medical Surgical, Oncology, ICU patient and process

*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, or Washington Residents Only: The salary range for this role is $88,000 to $173,200 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.