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Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

Position in this function is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices.

If you are located in California, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each internal and external customer

• Perform all functions of the UM nurse reviewer

• Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards

• Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request

• Ensures the denial reason is in the appropriate grade level and is easily understandable

• Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria, or protocols based on the type of denial

• Selects the correct level of hierarchy and applied correctly based on the medical information available

• Provides relevant clinical information to the request and the criteria used for decision-making

• Ensures that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria applied

• Evaluates out-of-network and tertiary denials for accessibility within the network

• Performs a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelines

• Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination

• Escalates non-compliant cases to UM compliance and consistently reports on denial activities

• Collaborates with UM compliance for continued quality improvement efforts for adverse determinations

• Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution

• Meets or exceeds productivity targets

• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

• Performs additional duties as assigned

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

• Current LVN license in California

• 1+ years of experience as an UM nurse reviewer

• 1+ years of recent clinical experience working as an LVN/LPN

Preferred Qualifications:

• Bachelor’s degree in Nursing

• 3+ years of managed care utilization

• 1+ years of experience performing essential functions of a CDU nurse

Knowledge, Skills, Abilities:

• Computer literate

• Proficient in Microsoft Office Suite, knowledge of utilization management platform and capacity to navigate varied web-based platform for decision making

• Ability to type 25 wpm

• Manual dexterity to use/handle equipment and instruments

• Proven solid critical thinking and problem-solving skills to perform essential functions of the CDU nurse

• Knowledge and understanding of managed care rules and regulations; to include, but not limited to, federal regulations, state regulations, health plan requirements and NCQA standards

• Knowledge and understanding of managed care clinical-decision making tools; to include, but not limited to, Medicare coverage determinations, Medi-cal criteria, MCG and health plan criteria

• Ability to effectively communicate and collaborate with physicians, patients, families, and ancillary staff

• Ability to make sound, independent judgments, and act professionally under pressure

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California 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.

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