Utilization Management & Clinical Validation RN

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 inclusion, talented peers, comprehensive benefits and career development opportunities.

About the role

The Utilization Management & Clinical Validation RN will accurately and efficiently review and extract pertinent case details from patient medical records, and craft strongly defensible appeal letters per process instructions and the department's/company's guidance. They will have a working knowledge of encoder use and selecting appropriate, supportable appeal arguments from evidence-based, peer-reviewed medical literature as provided, as well as interpreting and utilizing ICD-9 and 10, CM and PCS, CPT coding system, and HCPCS guidelines. They will recommend changes to coding which will retain, lessen, or increase financial impact when analysis of the chart indicates opportunities.

Responsibilities

• Adhere to approved schedule and arrive to work timely
• Maintain accurate accounts of time off in both Verint and HR Direct as per guidelines, and follow directives for time off, schedule changes, etc.
• Compose appeal letters to include appropriate data extraction, construction of well-written appeals letters with proper grammar, utilization of appeal tools including pre-constructed templates, and inclusion of appropriate medical literature references
• Use and demonstrate fluency with encoders, coding clinics, ICD-9 and 10 guidelines, CM and PCS, CPT coding system, and HCPCS guidelines
• Adhere to company policies and procedures as well as policies, procedures, and laws
• Understand and comply with HIPAA confidentiality requirements
• Support and promote OPAS, Optum, and the enterprise goals and mission
• Build relationships across Optum, OPAS, OGA, and clients
• Collaborate with peers to assure continuity of communication and execution of deliverables as needed
• Adhere to quality and productivity expectations
• Participate in and contribute to meetings as appropriate
• Maintain organization on the team and ensure everyone conducts themselves professionally
• Remain up to date with all learning modules, competencies, and state-required licenses
• Perform other related duties, tasks, and processes as required by leadership
• Establish priorities, be self-motivated, work independently, and follow instructions with supervision and structure
• Maintain a positive attitude and function as a collaborative team member

Requirements

• Associate degree or higher
• Unrestricted RN license required in state of residence
• 3+ years of clinical experience in ED/Telemetry/Critical Care
• 2+ years of experience in clinical validation appeals
• Working knowledge of Microsoft Word
• Effective communication skills
• Excellent typing skills with a minimum of 45 WPM

Preferred Qualifications

• Pre-authorization experience
• License certified coder
• Utilization Management experience
• Case Management experience
• Knowledge of Milliman Criteria
• Certified Case Manager (CCM)

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)

Pay

The salary for this role will range from $60,200 to $107,400 annually based on full-time employment.

Schedule

You will enjoy the flexibility to telecommute* from anywhere within the U.S.