Pharmacy Utilization Management RN - Optum CA - Remote
Company: UnitedHealth Group
Location: Los Angeles
Posted on: May 17, 2024
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Job Description:
For those who want to invent the future of health care, here's
your opportunity. We're going beyond basic care to health programs
integrated across the entire continuum of care. Join us to start
Caring. Connecting. Growing together.
Position in this function is responsible for the review and
evaluation of specialty injectable information and documentation.
Reviews documentation and interprets data obtained from clinical
records or systems to apply appropriate clinical criteria and
policies in line with regulatory and accreditation requirements for
member and/or provider issues. Independently coordinates the
clinical resolution with internal/external clinician support as
required.
If you are located in PST time zone states, you will have the
flexibility to work remotely* as you take on some tough
challenges.
Primary Responsibilities:
Reviews documentation and evaluates potential quality of care
issues based on clinical policies and benefit determinations
Considers all documented system information as well as any
additional records/data presented to develop a determination or
recommendation
Data gathering requires navigation through multiple system
applications
Staff may be required to contact the providers of record, vendors,
or internal departments to obtain additional information
Evaluates documentation/information to determine compliance with
clinical policy, regulatory and accreditation guidelines
Accurately applies review requirements to assure case is reviewed
by a practitioner with clinical expertise for the issue at hand
Commands a comprehensive knowledge of complex delegation
arrangements, contracts, clinical criteria, benefit plan structure,
regulatory requirements, company policy and other processes which
are required to support the review of the clinical
documentation/information
Pro-actively and consistently applies the regulatory and
accreditation standards to assure that activities are reviewed and
processed within guidelines
Condenses complex information into a clear and precise clinical
picture while working independently
Positions in this function require various nurse licensure and
certification based on role and grade level. Licensure includes RN
or LPN/LVN, depending on grade level, with current unrestricted
licensure in applicable state. LPN/LVN roles work under the direct
supervision of an RN or MD. Function is responsible for utilization
management which includes Concurrent Review (on-site or telephonic
Inpatient Care Management). Performs reviews of current inpatient
services. Determines medical appropriateness of inpatient and
outpatient services following evaluation of medical guidelines and
benefit determination. *Employees in jobs labeled with 'SCA' must
support a government Service Contract Act (SCA) agreement.
Generally work is self-directed and not prescribed
Works with less structured, more complex issues
Serves as a resource to others
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
Requires an RN with unrestricted active license
3+ years of clinical experience
Managed Care
Medicare experience
Prior Authorization
Utilization Review
Preferred Qualifications:
Pharmacy prior authorization review
*All employees working remotely will be required to adhere to
UnitedHealth Group's Telecommuter Policy
Nevada, Washington or California Residents Only: The hourly range
for this role is $28.03 to $54.95 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.
Keywords: UnitedHealth Group, Santa Monica , Pharmacy Utilization Management RN - Optum CA - Remote, Executive , Los Angeles, California
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