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RN Nurse Reviewer

4 months ago

Eden Prairie, Minnesota, United States UnitedHealth Group Full time

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.

Provide efficient, effective risk management according to each specific benefit plan for PreferredOne products, using utilization review.

You will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

  • Utilize the Preferred One medical criteria and those of other regulatory bodies, (i.e. NCQA, DOH), the exempt and focused review programs, and the patient's benefit plan summary to perform medical necessity, level of service and appropriateness review
  • Perform inpatient and outpatient pre-admission, concurrent review and decision support based on medical necessity, appropriateness of treatment setting and length of stay utilizing Preferred One criteria and/or community standards and professional judgments
  • Document timely and concise information which clearly outlines the utilization review strategy online
  • Accurately apply benefit language to each review situation
  • Identify any cases that are at high-risk for complex discharge planning or case/risk management intervention and make appropriate referrals
  • Perform utilization reviews for complex medical conditions such as Transplants and NICU inpatient to meet the needs of internal and external customers
  • Perform utilization reviews and assist with Transition of Care and Extended Hour Nursing to meet the needs of internal and external customers
  • Perform Pre-Service and Post-Service Appeal reviews
  • Refer cases that do not meet medical necessity criteria to a medical reviewer for medical necessity determination. Coordinate peer review, medical determination and appeal
  • Identify before or at the time of admission, any cases which have high case management potential due to large dollar amounts, utilization of out of network provider, multiple providers requiring care integration, or complex discharge planning needs
  • Identify and appropriately transfer cases for Chronic Illness Management or Complex Case Management/Behavioral Health Case Management as appropriate
  • Work collegially with PreferredOne providers, requesting, providing, and collaborating in obtaining information as needed
  • In a timely fashion, contact Manager, Director and Account Manager to make recommendations for flexing or extending benefits to prevent the possibility of using more costly services with equivalent outcomes
  • Assist with the development of policies, procedures, criteria, exempt and focused review programs etc., as required, refine and revise the risk management process to better meet its dual goals of cost efficiency and quality care delivery
  • Through collaboration and sharing of information, work with other Preferred One staff to assist in identifying and solving problematic issues through provider education, contracting issues, focused review programs, etc.
  • Review claims, data from pharmacy benefit administrators and other information available to assess patients who have high case management potential or who would benefit from further integration of medical services
  • Monitor case information for quality and patient safety issues and refer as needed per company guidelines for further review
  • Ad hoc activities as designated by management, i.e. training and orienting other staff, arranging in-services, researching clinical information on the internet

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:

  • 5+ years of clinical experience
  • 2+ years of Utilization Management or Case Management experience in a managed health care setting
  • Proven excellent communication skills with the ability to interact and collaborate effectively with all levels of the organization and outside clients
  • Proven good interpersonal skills and ability to work effectively in an environment characterized by high levels of activities
  • Proven ability to multi-task and prioritize in a fast-paced environment

Preferred Qualifications:

  • Licensed as an R.N. in the State of Minnesota
  • Compact State Nursing License
  • Certified Case Manager
  • Experience in Case Management
  • Medical experience in NICU, Transplants, Rehabilitation, Surgical, Home Healthcare and Appeals
  • Knowledge of insurance industry including benefit plans, reinsurance and State and National mandates (requirements)

Special Requirements:

  • Compliance with regulatory and accrediting organizations (e.g., MDH, NCQA) and applicable laws and regulations (e.g., HIPAA, Affordable Care Act)
  • Adherence to internal quality control guidelines and processes (e.g., SOC1)

*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, or Washington Residents Only: The salary range for this role is $58,300 to $114,300 annually. 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: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.