(Remote considered)
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
Positions in this function require various nurse licensure and certification based on role and grade level. RN licensure is required, with current unrestricted licensure in applicable state or compact license. Medical Management UM Department includes prior-authorization clinical review, acute inpatient concurrent review, and post-acute LTAC,AIR, SNF concurrent review functions for utilization management.
This position is responsible for the daily operations of medical management UM teams. These teams encompass a staff of utilization review nurses Nurse (RN/LVN/LPN), and Clinical Administrative Coordinators. This position is also accountable for compliance with all regulatory agencies including NCQA, CMS, Appeals and Grievances, QIO, DMHC and the state board of nursing in applicable states managed. This position is responsible to assist to accomplish HEDIS, CORE, HOS, and STARR metrics, UM KPI metrics and the internal performance, quality, and affordability targets of the Medical Management Division. This area maintains oversight for data entry into multiple medical record system as related to medical management. Education and training is an integral part of this position for both employees of medical management and internal or external agencies in order to promote patient care. As a director there is an expectation that the position will conduct and lead meetings, participate in taskforces and ensures compliance with company policy, state, and federal programs.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Ensure the team provides appropriate education, training, support, and resources to all staff so that all compliance and customer service standards are met including the appropriateness of decision making, timeliness and completeness of all requests
- Provide support to the team to allow for growth and development and encourage the team to think “out of the box” for solutions
- Remove barriers so that staff can maintain high productivity and high levels of morale
- Evaluate reports, look for trends and identify key areas that need development
- Ensure coordination between other internal departments as well as external companies as appropriate
- Owns end to end process as related to multidisciplinary oversight
- Develops functional, market level, and/or site strategy, plans, production and/or organizational priorities
- Identifies and resolves technical, operational, and organizational problems outside own team
- Develops work plans and educational plans to best manage the day-to-day functions of multidisciplinary departments
- Organizes collaborative committees with the health plan to maintain the delegation of authority within the compliance requirements Medicare and NCQA
- Independently manage tasks towards priorities of the multidisciplinary department for Medical Management
- Collaborates on decisions to promote teamwork
- Collaborates with Senior Director of Operations, Medical Director and VP of Medical Management
- Lead meetings and processes towards improvement activities for multidisciplinary teams and medical management
- Provides input to leadership to enhance process flows and efficiencies while addressing initiatives, goals, and mission
- Accountable for performance of multiple markets or large department
- Broad operational oversight with strategic input
- Develops strategies for achieving departmental goals
- Collaborates with senior leaders and external stakeholders
- Director-level leader; develops managers and sets department goals
- Oversees full scope performance and improvement plans
- Solves region-wide operational or compliance challenges
- Develops strategies to meet department objectives
- Manages budgets for regions or large teams
- Standardizing processes across multiple regions
- Other duties as assigned in medical management
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 required
- Current active licensure as a registered nurse (RN)
- 5+ years of progressive experience in utilization management
- 3+ years of progressive leadership experience with direct reports
- Knowledge of healthcare regulations, utilization review processes, and medical necessity criteria
- Proficiency in application of utilization management criteria, such as InterQual or MCG
Preferred Qualifications:
- Master’s degree in business, nursing, or healthcare administration
- Proven excellent analytical, problem-solving, and decision-making skills
- Proven effective executive communication, interpersonal, and collaboration skills
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
The salary range for this role is $106,800 to $194,200 annually based on full-time employment. 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.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
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.