Job Description

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together.
The utilization management (UM) nurse is responsible for the supervisory oversight and direction of UM department activities to include prior authorization for post-acute services, medical necessity determinations, concurrent and retrospective reviews and discharge planning functions. The UM nurse actively participates in management decision making to verify compliance with all contract requirements. This position is based in Indiana.
If you reside in Indiana, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:

• Directs the activities of the UM staff, with direct supervision by the medical director and staff geriatrician regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care and other clinical and medical management programs
• Coordinates with the SIU manager to make sure service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation are timely submitted within five business days to enable recovery of overpayments or other appropriate action
• Aids, approves and intervenes as needed to determine medical necessity, appropriateness and extended length-of-stay decisions
• Assists inpatient care manager in UM of members with complex medical care involving numerous providers or frequent intervention
• Participates in State- or plan-required audits and complies with all reporting requirements by area of responsibility
• Oversees reporting and monitors potential high-cost cases, readmissions, UM statistics to include admits per thousand, bed days per thousand, length-of-stay and readmissions per thousand within 30 days of discharge
• Develops and implements action plans for improvement as needed

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:

• Current unrestricted RN license in Indiana
• 5+ years of relevant experience in Utilization Management
• Prior experience with Medicare and/or the LTSS or MLTSS population

Preferred Qualifications:

• Undergraduate degree
• 3+ years in a supervisory role in Utilization Management in a managed care environment

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $89,900 to $160,600 annually based on full-time employment. We comply with all minimum wage laws as applicable.
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Skills Required