AmeriChoice, a UnitedHealth Group company, is a recognized leader and innovator in providing managed health care solutions to its membership, which includes Medicaid, Medicare and SCHIP beneficiaries. With over a decade of growth and success, we are poised for continued expansion of our services in this dynamic marketplace. Our commitment to this specialized market makes a genuine difference in the lives of our 1.8 million members. Join us, do rewarding work, and build a great career.
We have an exciting dual career opportunity for an RN with clinical experience to join our team. As a Utilization Review Nurse (Case Manager), you will telephonically manage complex member cases by providing assessment, education and care coordination. The clinical coverage review process includes activities such as pre-determinations, benefit coverage determinations that stem from member/provider notifications, medical claim review, pre-service appeals and clinical claim appeals. You will also complete the clinical coverage review process through case/claim review, interpretation of plan benefit language and policy, as well as Medical Director/physician consultation. If you're ready to use your clinical skills without direct care and enjoy a schedule with no nights or weekends, we encourage you to apply.
Job Duties
- Performs utilization review at selected inpatient facilities
- Assesses and interprets customer needs and requirements.
- Identifies solutions to non-standard requests and problems.
- Solves moderately complex problems and/or conducts moderately complex analyses.
- Works with minimal guidance; seeks guidance on only the most complex tasks.
- Translates concepts into practice.
- Provides explanations and information to others on difficult issues.
- Coaches, provides feedback, and guides others.
- Acts as a resource for others with less experience.
- Receiving calls from hospitals to authorize services for members of all ages, will all types of conditions
- Entering data into the computer system while on the phone
- Monitoring (concurrent review) and managing cases while patients are in the hospital
- Assisting hospitals with discharge planning and authorizations for post-discharge services such as homecare, DME, etcâ¦
- Assisting with projects/committee work within the department as needed
- Managing complex cases of adults with special needs, diabetes and other diseases
- Evaluating referrals of members
- Coordinating members' care
- Collaborating with healthcare providers and family members in developing a health plan
- Providing member education
- Assessing members' conditions
- Identifying cost-saving initiatives without compromising care
- Perform clinical coverage review of services, which require interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of the relevant clinical information.
- Partner with Care Coordination, Health Plan, Account Management, and staff from other areas regarding clinical coverage review cases.
- Ability to communicate in writing and verbally, all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations.
- Telephonic discussions with health care providers and members to explain benefit coverage determinations and to obtain additional clinical information.
- Ensure consistent application of the clinical coverage review process for all functional components.
- Navigate within the claim/Care Coordination systems to obtain information necessary to make sound clinical decisions on service requests.
- Document case review findings, actions, and outcomes in accordance with Clinical Coverage Operations policy.
- Collaborate with training staff to identify training needs and development of training plans.
Qualifications/Requirements
- A current unrestricted RN license in the state of NE and previous clinical nursing experience are required.
- 2-5 years clinical experience
- Solid clinical experience in acute, hospital or outpatient care is a must.
- Utilization Management is ideal, but we're willing to train the right candidate.
- Bachelor's degree preferred.
- Bilingual Speaking (English/Spanish) highly preferred.
- Certification in case management is preferred, as is experience with complex case management.
- Proficiency in Microsoft Office applications is needed.
- Previous Utilization/Case Management or claim review experience
- Sound clinical judgment
- Demonstrated understanding of managed care concepts
- Strong problem solving and decision making skills
- Strong departmental team player
- Good written and verbal communication skills
- Personal computer skills
- Strong time management and prioritization skills
- Excellent customer service skills including a sense of urgency and ownership for resolving issues
- Strong interpersonal skills at an individual and team level
- Ability to be flexible, adjust quickly and react positively to change
- Knowledge of ICD-9 and CP coding
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. |
