About the position

Responsibilities

  • Perform initial and concurrent review of inpatient cases applying evidenced-based criteria (InterQual criteria)
  • Discuss cases with facility healthcare professionals to obtain plans-of-care
  • Collaborate with Optum Enterprise Clinical Services Medical Directors on performing utilization management
  • Participate 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 downstream partners
  • Apply clinical expertise when discussing cases 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
  • Facilitate timely and appropriate care and effective discharge planning
  • 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 audit activities and meetings

Requirements

  • Active, unrestricted RN license in state of residence
  • 3+ years of clinical nursing experience in an Acute Inpatient Hospital setting
  • 1+ year of experience in Utilization Review utilizing InterQual Guidelines, either within an Acute Inpatient Hospital setting or within a health insurance company
  • Proficiency in computer skills - Windows, IM, Excel (Microsoft Suite), Outlook, clinical platforms
  • Designated workspace and access to install secure high-speed internet via cable / DSL in home
  • Permanent residence in Eastern Standard Time or Central Standard Time zones

Nice-to-haves

  • Bachelor's degree
  • Compact RN license
  • 2+ years acute inpatient case management experience/Utilization Reviewer
  • Managed care experience
  • Experience performing discharge planning

Benefits

  • Comprehensive benefits package
  • Incentive and recognition programs
  • Equity stock purchase
  • 401k contribution