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Position in this function is responsible for all activities associated with Utilization Management (UM) programs. Ensures all UM activities are efficient, effective and meet regulatory requirements. Monitors staff performance, provides mentorship and recognizes and manages departmental opportunities that impact outcomes.

Primary Responsibilities:

• 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

• Develops and maintains strong and lasting team member and partner relationships

• Ensure that the team meets performance goals and complies with timeliness, documentation, notification of cases based on LOB requirements

• Exhibits behavior and communication skills that demonstrate commitment to superior patient care, patient experience and patient outcomes

• Proven and effective problem-solving, critical thinking and decision making skills

• Ensures that the regional care management programs meet and exceed compliance adherence; CMS, health plan delegation and quality

• Develops, implements and analyzes data to support best practice outcomes for care management programs

• Meets auditing timeframes and proactively manages gaps and interventions

• Identifies need for and participates in the development and implementation of UM operating procedures

• Identifies and proactively manages staffing efficiencies and productivity, ensuring efficient management of resources

• Collaborates with staff, stakeholders and clinicians to provide a patient centric approach to UM

• Serves as subject matter expert in UM- appropriate use, interpretation of clinical criteria review process such as National Coverage

• Determination, Local Coverage Articles, Local Coverage Determination Health plan Medical Coverage Policies

• Supports and guides staff to be accountable in decision making

• Develops tools and ensures resources are available to support accountable decision making

• 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

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:

• Graduate from an accredited school of Nursing

• Current, unrestricted RN or LVN license in California

• 2+ years of experience in utilization management or (prior authorization review) nurse

Preferred Qualifications:

• 2+ years of experience in a leadership role

• Experience in managed care

California Residents Only: The salary range for this role is $88,000 to $173,200 annually. 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.

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: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment