Utilization Management Nurse, Per Diem

OVERVIEW OF POSITION: 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. ____________________________________________________________________________________ ESSENTIAL FUNCTIONS: • Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer. • Perform all functions of the UM nurse reviewer. • Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards. • Constructs 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. • Ensures the denial reason is in the appropriate grade level and is easily understandable. • Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial. • Selects the correct level of hierarchy and applied correctly based on the medical information available. • Provides relevant clinical information to the request and the criteria used for decision-making. • Ensures 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. • Evaluates out-of-network and tertiary denials for accessibility within the network. • Performs a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelines. • Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination. • Escalates non-compliant cases to UM compliance and consistently reports on denial activities. • Collaborates with UM compliance for continued quality improvement efforts for adverse determinations. • Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution. • Meets or exceeds productivity targets. • Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. • Performs additional duties as assigned. EDUCATION: • 1 or 2 years of post-high school education or a degree from a two-year college. • Graduation from an accredited school of Nursing. • Current California RN license. EXPERIENCE: Minimum: • 1 year of experience as an UM nurse reviewer. • Score at least 98% or higher on the CDU nurse competency testing. Preferred: • 3 to 5 years of managed care utilization and management experience. • 1 year of experience performing essential functions of a CDU nurse. KNOWLEDGE, SKILLS, ABILITIES: • Computer literate. • Proficient in Microsoft Office Suite, knowledge of utilization management platform and capacity to navigate varied web-based platform for decision making. • Ability to type 25 wpm. • Manual dexterity to use/handle equipment and instruments. • Must possess strong critical thinking and problem-solving skills to perform essential functions of the CDU nurse. • Knowledge and understanding of managed care rules and regulations; to include, but not limited to, federal regulations, state regulations, health plan requirements and NCQA standards. • Knowledge and understanding of managed care clinical-decision making tools; to include, but not limited to, Medicare coverage determinations, Medi-cal criteria, MCG and health plan criteria. • Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff. • Ability to make sound, independent judgments and act professionally under pressure. 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