RN Case Manager

7 days ago


Phoenix, Arizona, United States UnitedHealth Group Full time
Bariatric Prior Authorization RN Case Manager

At UnitedHealth Group, we're committed to helping people live healthier lives and making the health system work better for everyone. As a Bariatric Prior Authorization RN Case Manager, you'll play a critical role in ensuring that our members receive the care they need to achieve their health goals.

Key Responsibilities:
  • Conduct pre-service clinical coverage reviews of services that require notification, using applicable benefit plan documents, evidence-based medical policy, and nationally recognized clinical guidelines and criteria.
  • Determine medical appropriateness of services following evaluation of medical guidelines and benefit determination.
  • Make outbound calls to assess members' current health status and case manage members in the pre-operative and post-operative phases of Bariatric surgery to ensure a positive outcome.
  • Identify gaps or barriers in treatment plans and coordinate ongoing care with providers.
  • Provide patient education to assist with self-management and healthy lifestyle changes.
  • Stay connected with members to help them stay on the right track regarding diet and weight loss goals.
  • Document and track progress from initial assessment through post-operative care.
  • Interact with Medical Directors on challenging cases.
  • Make post-operation calls to ensure that discharged members receive the necessary services and resources.
  • Prioritize cases based on appropriate criteria, such as date of service, urgency, and expedited needs.
  • Ensure compliance with applicable federal and state requirements and mandates.
Requirements:
  • Current, unrestricted RN license in your state of residence.
  • Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses.
  • 3+ years of experience in a hospital setting managing medical/surgical, ICU, bariatric patients, or complex case management.
  • Intermediate level of proficiency with Microsoft Word, including the ability to navigate a Windows environment.
  • Ability to work until 8:00pm at least one night per week.
  • Access to high-speed internet from home (Broadband cable, DSL, or Fiber).
  • Designated workspace from home.
Preferred Qualifications:
  • Bachelor's Degree.
  • Certified Case Manager (CCM).
  • Compact/Multi-State RN license.
  • Bariatric experience as the main focus of your job.
  • Prior Authorization/Utilization Management/Review experience.
  • Post-surgical experience.
  • Patient education experience.
  • Discharge planning experience.
  • Case Management/Care Coordination experience.
  • Managed care background.
  • Knowledge of Milliman (MCG) or InterQual criteria.
  • Reside in a compact license state with a compact license.


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