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Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Utilization Management Specialist collaborates with the care team to confirm the level of care and authorization for services. Reviews medical records and prepares clinical reviews for medical necessity and authorization. Is also responsible for facilitating the denial and appeal process.

If you reside near Minneapolis, MN, you will enjoy the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

• Ensures procedures are appropriate and necessary per health benefit plans

• Assesses clinical data from medical records to assure appropriateness of patient's admission

• Utilizes screening criteria to determine patient status

• Assures the medical record has the proper physician order and/or clinical documentation

• Monitors continued stay to identify potential issues and communicates results and opportunities to nurses, physicians, finance, case managers, and payers

• Evaluates potential denials or payment issues and initiates communication with physician or clinician regarding next steps

• Prepares and facilitates appeals for denied claims

• Facilitates peer to peer requests between admitting, attending physician, and the payer physician

• Other 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:

• Licensed Registered Nurse - MN Board of Nursing

• 2+ years of experience in an acute hospital setting

Preferred Qualifications:

• Bachelor’s Degree in nursing

• 2+ years of case management experience

• 2+ years of utilization management experience

• 6+months of experience using InterQual, MCG, or other admission criteria

• Epic Experience

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

The salary range for this role is $59,500 to $116,600 annually based on full-time employment. 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: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, 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.

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

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