25 days old

RN - Utilization Management Review Nurse - Farmington, CT - 906734

Farmington, CT 06032
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  • Job Code
    906734
Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieveyour lifes best work.(sm)
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ProHealth Physicians, part of OptumCare
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If you want to get way ahead in your career, it makes sense to be with an organization's that's way ahead of the curve. Formed in 1997, ProHealth Physicians has grown to become Connecticuts leading primary care physician organization. With over 90 locations throughout the state of Connecticut, our family of primary care doctors and specialists care for more than 360,000 people statewide. In fact, ProHealth serves every county and provides roughly ten percent of the primary care delivered to patients in the state. We're leaders in thinking and in serving our communities. For instance, we're a C.M.S. approved Accountable Care Organization (ACO), covering over 30,000 Medicare patients associated with our community-based primary care providers. We're also nationally recognized as a NCQA Level III Medical Home. That kind of progressive leadership makes us perfect fit for OptumCare and UnitedHealth Group's expanding family of providers. This is a place where you can stay way ahead as you doyour life's best work.(sm)
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Facilitates cost effective care throughout the continuum utilizing a collaborative multi-disciplinary approach. Implements the nursing process including assessment, planning, implementing, coordinating, monitoring and evaluating options and services for patients and families experiencing complex/catastrophic illnesses. Responsible for the assurance of quality medical management and cost containment in the Utilization (Medical) Management department in the IPA. This includes, but is not limited to: utilization and referral management and total case management, in both the inpatient and outpatient settings.
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THIS POSITION IS PARTIALLY REMOTE / PARTIALLY IN FARMINGTON CT PROHEALTH PHYSICIANS OFFICE
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Primary Responsibilities:
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    Daily telephonic rounds, reviewing of medical records, concurrent review, and discharge planningon inpatients with arrival at facilities in the morning ideally between 0800 and 0900
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  • Daily telephonic/inpatient rounds withhospital staff (Hospitalists and Care Managers)
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  • Communicates discharges tothe IPA Provider by 12 noon
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  • Reviews inpatient cases with Director on a daily basis
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  • Documents Milliman Guideline(s) on every inpatient case within 24 hours of receipt and updates guideline as hospitalization continues
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  • Notifies patients Primary Care Physician of admission, discharge and discharge plan within 24 hours of each event as appropriate
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  • Analyzes medical cases for appropriateness and plans and coordinates all phases of care in conjunction with the Hospitalist, attending Physician, Specialists both in the inpatient and outpatient settings
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  • Utilizes the nursing process to establish individual patient goals and measures patients response to the plan of care for appropriate outcomes and intervenes appropriately
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  • Collaborates with physicians, patients, and families to formulate an optimal plan of care that meets all of the medical, psychosocial and financial needs of the patient
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  • Explores care options to reduce cost, decrease length of stay, curtail re-admission and influence quality outcomes
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  • Understands capitation vs. fee for service
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  • Knowledgeable regarding network providers and current contracted specialists
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  • Managescases according to delegation agreement requirements, including notifications regarding LOS >5 days
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  • Regularly communicates with Health Plans as appropriate
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  • Understands health plan benefits and contractual information
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  • Generates authorizations utilizing principles of UM
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  • Accurately uses database for daily documentation of clinical information, opportunity days, denied days and levels of care
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  • Follows policy and procedure for Denials and enters this information into the database with 24 hours of the event
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  • Assists with implementation of all policies and procedures in the group through knowledge and experience
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  • Meets all health plan contract compliance directives for utilization
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  • Maintains ongoing communication and feedback with customers and/or clients in order to support needs and resolve problems.
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  • Attends weekly/monthly group committees as requested
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  • Manages error reports on a weekly basis
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  • Communicates activities and progress of assigned committees and teams to appropriate staff
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  • Identifies and refers members to Case Managementprior to discharge or as deemed appropriate through referral review
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  • Participates in IPA Grand Rounds providing a concise history and overview of the members progress and discharge plan.Attends any onsite specialty facility rounds as appropriate
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  • Performs On Call duties as requested
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  • Travel as needed
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Youll 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.
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Required Qualifications:
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  • Graduate from an accredited program for professional nursing education.
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  • Current, unrestricted RN License in the State of Connecticut.
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  • Two or more years clinical experience in an acute care setting (i.e., ICU, CCU, ER, Med/Surg)
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  • Two or more years CM or URor related health care experience
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  • One yearmanaged care experience
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  • Valid Drivers license and insurance
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  • Proficient in Microsoft Office
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    Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive VoiceResponse (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained

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    You will be asked to perform this role in an office setting or other company location

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Preferred Qualifications:
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  • Bachelor / Masters of Science in Nursing preferred (BSN/MSN)
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  • CCM Certification
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  • Three or more years managed care experience
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Skills:
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  • Strong ability to work effectively with physicians and ancillary staff
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  • Excellent communication skills bothwritten and verbal
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  • Ability to perform complex problem solving related to health care utilization
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  • Self-motivated with strong quantitative and organizational skills
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  • Ability to look at challenges as opportunities
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  • Knowledge of general PMG/IPA operations
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  • Flexible and adaptable of schedule to attend various meetings and/or promotional events
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  • Participates in a team environment supporting and respecting all members, encouraging achievement of group goals
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  • Able to problem solve and make decisions independently
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  • Ability to manager competing priorities and work under significant time constraints
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  • Ability to synthesize large volumes of information
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Careers with Optum.Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to doyour life's best work.(sm)
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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.
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UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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Job Keywords:RN, Registered Nurse, UM Nurse, Utilization Management Nurse, CT, Connecticut, Utilization Review Nurse

Posted: 2020-12-25 Expires: 2021-02-14

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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RN - Utilization Management Review Nurse - Farmington, CT - 906734

UnitedHealth Group
Farmington, CT 06032

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