RN Utilization Management - Remote CA PST ID-5603

January 3, 2025

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.

Put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. As a Utilization Management Nurse at UnitedHealth Group, you will make sure our health services are administered efficiently and effectively. You'll assess and interpret member needs and identify solutions that will help our members live healthier lives. This is an inspiring job at a truly inspired organization.

If you are have CA RN license and is willing to work in PST, you will have the flexibility to work remotely* as you take on some tough challenges.

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Primary Responsibilities

Perform initial and concurrent review of inpatient cases applying InterQual criteria for approval and sending to Medical Directors if review is necessary for determining an adverse determination
Discuss cases with facility healthcare professionals to obtain plans-of-care
Collaborate with Optum Medical Directors on performing utilization management
Participation in discussions with the Clinical Services team to improve the progression of care to the most appropriate level
Consult with the Medical Director as needed for complex cases and make appropriate referrals to sister segments
Apply clinical expertise when discussing case with internal and external Case Managers and Physicians
Identify delays in care or services and manage with MD
Follow all Standard Operating Procedures in end to end management of cases
Obtain clinical information to assess and expedite alternate levels of care
Participate in team meetings, education discussions and related activities
Maintain compliance with Federal, State and accreditation organizations
Identify opportunities for improved communication or processes
Participate in telephonic staff meetings

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

Undergraduate degree or equivalent experience
Unrestricted RN license required in state of California
3+ years of Managed Care and/or Clinical experience
Must be willing to work 8:00 AM - 5:00 PM PST

Preferred Qualifications

Certified Case Manager (CCM)
Pre-authorization experience
Utilization Management experience
Case Management experience
Knowledge of InterQual guidelines
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.