Central Denials UM LVN - Remote CA at UnitedHealth Group
About the position
For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions. The position in this function is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices. If you are located in California, you will have the flexibility to work remotely as you take on some tough challenges. 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.
Responsibilities
Consistently exhibits behavior and communication skills that demonstrate Optum's commitment to superior customer service, including quality, care and concern with each internal and external customer.
,
Perform all functions of the UM nurse reviewer.
,
Compose denial letters in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards.
,
Construct denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member's condition and request.
,
Ensure the denial reason is in the appropriate grade level and is easily understandable.
,
Ensure the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria, or protocols based on the type of denial.
,
Select the correct level of hierarchy and apply it correctly based on the medical information available.
,
Provide relevant clinical information to the request and the criteria used for decision-making.
,
Ensure that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria applied.
,
Evaluate out-of-network and tertiary denials for accessibility within the network.
,
Perform a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelines.
,
Consult with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination.
,
Escalate non-compliant cases to UM compliance and consistently report on denial activities.
,
Collaborate with UM compliance for continued quality improvement efforts for adverse determinations.
,
Identify gaps in training or process impacting the overall compliance of adverse determinations and communicate in writing an effective performance improvement solution.
,
Meet or exceed productivity targets.
,
Use, protect, and disclose Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
,
Perform additional duties as assigned.
Requirements
Graduation from an accredited Licensed Vocational Nurse program.
,
Current LVN license in California.
,
1+ years of experience as an UM nurse reviewer.
,
1+ years of recent clinical experience working as an LVN/LPN.
Nice-to-haves
Bachelor's degree in Nursing.
,
3+ years of managed care utilization.
,
1+ years of experience performing essential functions of a CDU nurse.
Benefits
Comprehensive benefits package.
,
Incentive and recognition programs.
,
Equity stock purchase.
,
401k contribution.
Apply Now
For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions. The position in this function is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices. If you are located in California, you will have the flexibility to work remotely as you take on some tough challenges. 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.
Responsibilities
Consistently exhibits behavior and communication skills that demonstrate Optum's commitment to superior customer service, including quality, care and concern with each internal and external customer.
,
Perform all functions of the UM nurse reviewer.
,
Compose denial letters in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards.
,
Construct denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member's condition and request.
,
Ensure the denial reason is in the appropriate grade level and is easily understandable.
,
Ensure the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria, or protocols based on the type of denial.
,
Select the correct level of hierarchy and apply it correctly based on the medical information available.
,
Provide relevant clinical information to the request and the criteria used for decision-making.
,
Ensure that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria applied.
,
Evaluate out-of-network and tertiary denials for accessibility within the network.
,
Perform a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelines.
,
Consult with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination.
,
Escalate non-compliant cases to UM compliance and consistently report on denial activities.
,
Collaborate with UM compliance for continued quality improvement efforts for adverse determinations.
,
Identify gaps in training or process impacting the overall compliance of adverse determinations and communicate in writing an effective performance improvement solution.
,
Meet or exceed productivity targets.
,
Use, protect, and disclose Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
,
Perform additional duties as assigned.
Requirements
Graduation from an accredited Licensed Vocational Nurse program.
,
Current LVN license in California.
,
1+ years of experience as an UM nurse reviewer.
,
1+ years of recent clinical experience working as an LVN/LPN.
Nice-to-haves
Bachelor's degree in Nursing.
,
3+ years of managed care utilization.
,
1+ years of experience performing essential functions of a CDU nurse.
Benefits
Comprehensive benefits package.
,
Incentive and recognition programs.
,
Equity stock purchase.
,
401k contribution.
Apply Now