General Job Profile
- Generally work is self-directed and not prescribed
- Works with less structured, more complex issues
- Serves as a resource to others
If you are located in Hawaii, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities
- Assesses and interprets customer needs and requirements
- Identifies solutions to non-standard requests and problems
- Solves moderately complex problems and/or conducts moderately complex analyses
- Works with minimal guidance; seeks guidance on only the most complex tasks
- Translates concepts into practice
- Provides explanations and information to others on difficult issues
- Coaches, provides feedback, and guides others
- Acts as a resource for others with less experience
Functional Competencies
CPS_Conduct Non-Clinical Research to Support Determinations
- Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) -Validate that cases/requests for services require additional research
- Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources)
- Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
- Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
CPS_Review Existing Clinical Documentation
- Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) -Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
- Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs)
- Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
- Apply understanding of medical terminology and disease processes to interpret medical/clinical records
- Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
- Review care coordinator assessments and clinical notes, as appropriate
CPS_Conduct Clinical Research to Support Determinations
- Identify relevant information needed to make medical or clinical determinations
- Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical policies, Coverage Determination Guidelines [CDG], National Comprehensive Cancer Network [NCCN], state/federal mandates) -Review/interpret other sources of clinical/medical information to support clinical or medical determinations (e.g., previous diagnoses, authorizations/denials, case management documentation)
- Obtain information from patients, providers and/or care coordinators as needed to verify services rendered and/or recommend additional options (e.g., Organization Determination Appeals and Grievance [ODAG], steerage calls)
- Apply knowledge of applicable state/federal mandates, benefit language, medical/ reimbursement policies and consideration of relevant clinical information to support determinations
- Collaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e.g., Medical Directors and their staff, Optum, UHC, Account Management)
CPS_Make Final Determinations Based on Clinical and Departmental Guidelines
- Demonstrate understanding of business implications of clinical decisions to drive high quality of care
- Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS, NCQA/URAC accreditation)
- Ask critical questions to ensure member- and customer-centric approach to work
- Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
- Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
- Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes
- Use appropriate business metrics to optimize decisions and clinical outcomes
- Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up)
CPS_Achieve and Maintain Established Productivity and Quality Goals
- Meet/exceed established productivity goals
- Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations -Manage/prioritize workload and adjust priorities to meet quality and productivity goals
CPS_Drive Effective Clinical Decisions Within a Business Environment
- Ask critical questions to ensure member/customer centric approach to work
- Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as needed
- Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
- Identify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performance
- Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, healthcare reform, URAC/NCQA/ERISA/state accreditation)
Required Qualifications
- Valid RN license in Hawaii
- Residence in Hawaii
- 3+ years of RN experience in an acute setting
- Advanced computer proficiency (Microsoft Word, Outlook, and Internet)
- Saturday availability
Preferred Qualification
- 3+ years of experience as an RN in utilization management
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
The hourly pay for this role will range from $29 - $52 per hour based on full-time employment.