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The Clinical Review Coordinator is responsible for concurrent review for post-acute levels of care. Review clinical documents and complete reviews based on medical necessity and InterQual criteria. Focuses on comprehensive discharge planning upon admission and coordination of care throughout the duration of member’s stay. Partners with physicians, providers, and other members of the team to determine the most appropriate level of care for the member.

Monday through Friday 8AM -5PM CST. Must have a TN State RN License and Reside in Tennessee

Primary Responsibilities:

• Request and review member’s clinical information from providers

• Perform utilization review of inpatient cases using Interqual Criteria and updating authorizations on a timely basis

• Completes all assigned cases within required timeframes (TAT)

• Meets performance metrics with goal benchmarks

• Participate in rounds providing accurate clinical information to Manager, Medical Director, and other members of the team.

• Identify and evaluate delays in care

• Collaborate with provider for discharge planning and readmission prevention plan upon admission and through continued stay reviews

• Collaborate with other members of team: acute long-term care, acute rehabilitation, or skilled nursing facilities to move member through the care continuum

• Consult with the Medical Director for complex cases

• Identify opportunities for improved communication or processes

• Evaluate members ongoing needs and complete referrals to outpatient programs as appropriate

• Process and document all case activities per SOPs, Job Aides, and DES; follows Model of Care

• Participate in team meetings, education discussions, and related activities; completes assigned learning timely

Professionalism:

• Personal and Professional Accountability:

• Foster a positive work environment: assume positive intent, adapt to change in a positive manner

• Ability to hold self accountable for performance and results.

• Answer for one’s own behavior and actions.

• Career Planning:

• Develops own career path

• Sets self development goals and seeks challenging assignments

• Demonstrates a mind-set in which continuous learning and personal growth are an expectation.

• Ethics: Integrate high ethical standards and UHG core values into everyday work activities.

Integrity Value: Act Ethically

Relationships Value: Act as a Team Player; Communicate Effectively

Compassion Value: Focus on Customers

Innovation Value: Support Change and Innovation

Performance Value: Make Fact-Based Decisions; Deliver Quality Results

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:

• RN License for the state of Tennessee and Must reside in Tennessee

• 3+ years total experience including recent clinical experience in an inpatient/acute setting

• Experience in acute long-term acute care, acute rehabilitation, or skilled nursing facilities

• Experience in discharge planning and/or chart review

• Proficient computer skills

• Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously

• Proven ability to quickly adapt to change and drive innovation within team and market

• Proven ability to possess a high level of organizational skills, self- motivation, and ability to manage time independently

• Proven ability to work across functions and businesses to achieve business goals

• Proven ability to develop and maintain positive customer relationships

• Proven exceptional verbal and written interpersonal and communication skills

• Dedicated work area established that is separated from other living areas and provides privacy

• Live in a location that can receive a UnitedHealth Group approved high-speed internet connection

Preferred Qualifications:

• Bachelor’s degree

• 2+ years case management/utilization review

• Experience with Interqual criteria guidelines

• Experience working with Commercial, Medicare, and Medicaid plans

• Utilization Review background in managed care

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