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LPN, Utilization Management Nurse

Company: Optum
Location: Tacoma
Posted on: October 17, 2020

Job Description:

Utilization Management Nurse

Northwest Physicians Network is now offering a qualified candidate the opportunity to join our team as a Utilization Management Nurse . Our company values innovative problem solvers, promotes personal and professional growth and provides a supportive working environment that affords all its employees a healthy work/life balance.

The Utilization Management Nurse conducts reviews of requested healthcare services and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures. This position collaborates with patients, families and stakeholders to provide the level of care necessary to meet the patients’ needs. The UM Nurse provides planning and care coordination to facilitate transition plans to the appropriate level of care across the care continuum.

Northwest Physicians Network creates the opportunity for independent private practitioners to thrive in Washington State. By supporting clinical integration and data driven quality improvement, we have created a high value delivery network, making it possible for our providers to remain focused squarely on their patients.

Status: Regular, Full-time, FLSA Non-exempt

Competitive Benefits

Primary responsibilities will include:

Communicates directly with providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services

Performs utilization and concurrent reviews of all inpatient stays using InterQual/Milliman criteria, approves bed days, identifies and evaluates delays in care, initiates discharge planning, arranges alternative care settings when medically appropriate

Manages and follows relevant time frame standards for conducting and communicating utilization review determinations

Works closely with relevant medical entities to assure patients are transitioned to appropriate levels of care and all supporting resources are available either through the healthcare benefits or other supporting entity

Prepares for oversight audits by the health plans and responds to appeal requests

Monitors and evaluates medical services and community-based resources to meet the individual patient’s health needs at time of care transitions

Follow up with ancillary contracted entities if services or resources have not been made available to the patient to assure that medical needs are being met

Makes appropriate care management referrals through triage process during care transition to case management staff

Reviews written requests for clinical services for medical appropriateness

Interfaces with referring practitioners or staff, to facilitate care alternatives within specified time restrictions

Facilitates understanding in the areas of case management, quality management, utilization management, patient education and preventive health guidelines to promote health plan expectations and refers patients for appropriate services

Responds to questions from medical offices, hospitals, and patients about the necessary steps of the medical referral authorization process

Manages utilization review authorizations, both verbal and written to assure high continuity of care for all managed care patients in the program and consistency of gathering specific information within the department to comply with policies and procedures.

Review and respond to all reconsideration and appeal requests within timeframes outlined by the health plan.

Work closely with patient’s family and social services to ensure proper information is disseminated to all stakeholders

Works closely with the CMO to obtain timely medical decisions on pended referrals and requests for medical services from health plans and providers

Notifies CEO, CMO, Clinical, Claims and Practice Support Directors of any costly medical cases that will reach stop-loss levels

Submit TPL notifications of any potential Workers Comp. or Third-Party Liability cases that NPN may not be financially responsible for to the appropriate departments

Minimum Requirements:

Education: Licensed Practical Nurse certification or Associates Degree in Nursing

Experience:

2 years’ experience in Utilization Review for Insurance or Community Based facility and/or experience in care transition management.

2 years clinical nursing experience Certification:

Registered or Licensed Practical Nurse required with current unrestricted Washington state license.

Current driver’s license

Careers with Optum.  Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. 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. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do  your life's best work.(SM)

Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are 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. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Keywords: Optum, Tacoma , LPN, Utilization Management Nurse, Other , Tacoma, Washington

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