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HCBS Utilization Management Nurse Position requires a District of Columbia RN License. This role works under the direct supervision of the DC Associate Director of Utilization Management Function is responsible for performing pre-service clinical coverage review of Private Duty Nursing (PDN) and Personal Care services (PCS) using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of HCBS services following evaluation of medical guidelines and benefit determination.
This role requires a high degree of coordination with external and internal business partners, including, but not limited to the UnitedHealthcare clinical services inpatient, intake/prior authorizations, appeals and grievance, quality, case and disease management, behavioral health, and other clinical specialty, external vendors, or national programs.
This position is offered for Telecommute Nationwide however you must hold an Active, Unrestrictive RN License for Washington D.C License
Primary Responsibilities:
- Intake of provider, care coordinator, and Continuity of Care HCBS (home and community-based service) assisted technology and environmental modifications authorization requests
- Review and processing of HCBS authorizations including SMW (Services My Way) budget review request
- Assist case management to determine approval and interventions needed, for the determination of medical necessity, appropriateness of HCBS services
- Engage with the National Letter Team to complete mailing of member and provider notification of decision
- Engage / follow-up with Medical Director to provide clinical information needed for review and application of clinical criteria for PDN request
- Works closely with medical director when issues and concerns regarding the appropriateness, quality or efficiency of care delivery are identified
- Engage / follow-up with Care Management for assessment of member care needs
- Extensive knowledge of the continuum of care
- Participate in planning and attending UM meetings
- Participate in planning and attending Secondary Review meetings
- Participates in state and internal audits and complies with all UM reporting requirements
- Always conduct themselves in a professional manner
- Work closely with the Associate Director of UM on HCBS issues and concerns
- Perform additional utilization management related duties as assigned
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:
- Unrestricted RN license in the District of Columbia
- 2+ years of clinical experience in health care clinical settings
- 2+ years working in a managed care setting
- 2+ years of utilization management experience
- Demonstrated intermediate-Advanced proficiency experience with Microsoft Office Suite programs (Word, Excel, Outlook)
- Available to work Monday through Friday in EST Time Zone
Preferred Qualifications:
- Experience working with HCBS authorizations and communicating with HCBS providers
- Experience in a work from home environment
- Demonstrated knowledge of District of Columbia Medicaid
- Proven knowledge of Utilization Management and authorization processes
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
Washington, D.C. Residents Only: The salary range for this role is $58,300 to $114,300 annually. 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.