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If you are able to work the Pacific standard time zone, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities: 

Core job functions/day-to-day responsibilities: 

• The Utilization Management Nurse is responsible for medical necessity review of any prospective referrals (inpatient, outpatient, home health, injectable medications, and/or DME/Orthotics/Prosthetics)
• Skilled and competent with the Health Plan’s Evidence of Coverage and Benefits, current MCG guideline application, CMS website navigation, Health Plan contracts; Computer savvy with use of multiple websites
• Consistently and accurately completes all required documentation including but not limited to timely completion of medical necessity review, accurate application of review criteria using the Level of Hierarchy per line of Business (Commercial, Medicare Advantage HMO, Dual Special Needs Plan (D-SNP), and Medi-Cal) and use of Standardized documentation
• Daily collaboration with UM Referral Management team; i.e., Care Coordinators, Care Managers, Managers and Medical Directors
• Communicates authorization or denial of services to appropriate parties and may include patient (or agent), attending / referring physician or facility administration
• Demonstrates accountability and ownership to referrals assigned
• Meets or exceeds productivity targets and Quality Audit compliance
• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

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: 

• Graduation from an accredited Licensed Vocational Nurse program
• Active, unrestricted LVN license in the state of California 
• 2+ years of referrals, utilization management experience

Preferred Qualifications: 

• 3+ years of experience working as an LVN/LPN
• Experience in an HMO or experience in a Managed Care setting
• General knowledge of medical terminology and ICD-10 and CPT/HCPCS coding

*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, Washington, D.C. 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.

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: 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.

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