Opportunities at Northern Light Health, in strategic partnership with Optum. Whether you are looking for a role in a clinical setting or supporting those who provide care, we have opportunities for you to make a difference in the lives of those we serve. As a statewide health care system in Maine, we work to personalize and streamline health care for our communities. If the place for you is at a large medical center, a rural community practice or home care, you will find it here. Join our compassionate culture, enjoy meaningful benefits and discover the meaning behind: Caring. Connecting. Growing together. 

Summary:  The Utilization Management RN provides feedback as requested to enhance negotiations with payers. Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent, and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation and support of medical necessity/level of care. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities

Schedule: Hours will vary 

If you reside in Maine, you will enjoy the flexibility to telecommute* as you take on some tough challenges

Primary Responsibilities:

• Validates authorization for all procedure / bedded patients UM pre-admission
• Ensuring acquisition of pre-certification authorization, urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services from third-party payers
• Obtains commercial payer authorization within the contractual timeframe at time of presentation, every third day, or as needed
• Proactively reduces the risk of denials
• Manages concurrent cases to resolution
• Partners with Revenue Cycle team to support resolution of retrospective denials
• Conducts initial review and continued stay review every third day for Medicare
• Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information
• Confirms that orders reflect level of care, severity of illness and intensity of service utilizing Level of Care Criteria.
• Establishes and communicates estimated Length of Stay (LOS) using Geometric Mean Length of Stay (GMLOS)
• Conducts Level of Care review using electronic system and documents outcomes. Contacts payers as applicable
• Refers cases with failed criteria to Physician Advisor and appeals as necessary
• Completes stratification tool to identify simple vs complex patient population
• Deploys representative within Utilization Review team to handle audits (internal and external)
• Responsible for coordinating and conducting utilization / medical necessity reviews for all payers upon admission & concurrently throughout the inpatient admission in compliance with the NL EMMC Utilization Management Plan
• Ongoing collaboration with Care Manager to ensure that patient’s condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care
• Performs other duties as assigned or required

What are the reasons to consider working for UnitedHealth Group?  Put it all together – competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
• More information can be downloaded at: http://uhg.hr/uhgbenefits

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:

• Bachelor’s degree in nursing (BSN)
• Current, unrestricted RN license in the state of employment or Compact RN license 
• 3+ years acute clinical practice or related health care experience

Preferred Qualifications:

• ACM, CCM or other certification applicable to utilization management within 3 years of hire
• Experience as a Utilization Management RN
• Case management experience
• Certified Case Manager (CCM)
• Experience or exposure to discharge planning
• Experience in utilization review and concurrent review 

Soft Skill:

• Strong communication and interpersonal skills, including ability to work collaboratively and cooperatively within a team including internal and external customers
• Strong organizational skills and ability to set priorities

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state, and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

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.

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