RN Telephone Utilization Manager - Farmington, CT


: $80,200.00 - $103,520.00 /year *

Employment Type

: Full-Time


: Healthcare - Nursing

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Position Description

We're making a strong connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path?

Apply today!

Primary Responsibilities:

  • Facilitate cost effective care throughout the continuum utilizing a collaborative multi-disciplinary approach
  • Implement the nursing process including assessment, planning, implementing, coordinating, monitoring and evaluating options and services for patients and families experiencing complex/catastrophic illnesses
  • Responsible for the assurance of quality medical management and cost containment in the Utilization (Medical) Management department in the IPA
  • Conduct referral and total case management in both inpatient and outpatient settings
  • Perform Utilization Management for Home Health, Outpatient Therapy, DME, Injectables, Procedures, Inpatient acute care, SNF Stay and Rehab Stay Authorizations
  • Complete daily telephonic rounds, reviewing of medical records, concurrent review, and discharge planning on inpatients with arrival at facilities in the morning ideally between 0800 and 0900
  • Communicate discharges to IPA by 12 noon
  • Review inpatient cases with UM Manager on a daily basis
  • Document Milliman Guideline(s) on every inpatient case within 24 hours of receipt and update guidelines as hospitalization continues
  • Notify patient's Primary Care Physician of admission, discharge and discharge plan within 24 hours of each event as appropriate
  • Analyze medical cases for appropriateness. Plan and coordinate all phases of care in conjunction with the Hospitalist, attending Physician, and Specialists both in the inpatient and outpatient settings
  • Utilize the nursing process to establish individual patient goals and measures patients' response to the plan of care for appropriate outcomes and intervenes appropriately
  • Collaborate with physicians, patients, and families to formulate an optimal plan of care that meets all of the medical, psychosocial and financial needs of the patient
  • Explore care options to reduce cost, decrease length of stay, curtail re-admission and influence quality outcomes
  • Demonstrate an understanding of capitation vs. fee for service
  • Knowledgeable regarding network providers and current contracted specialists
  • Managecases according to delegation agreement requirements, including notifications regarding Length Of Stay >5 days
  • Regularly communicate with Health Plans as appropriate
  • Understand health plan benefits and contractual information
  • Generate authorizations utilizing principles of UM
  • Accurately use database for daily documentation of clinical information, opportunity days, denied days and levels of care
  • Follow policy and procedure for denials and enter this information into the database with 24 hours of the event
  • Assist with implementation of all policies and procedures in the group through knowledge and experience
  • Assist in training/cross training of staff in conjunction with corporate department, to maximize effectiveness and utilize staff to their fullest potential
  • Meet all health plan contract compliance directives for utilization
  • Maintain ongoing communication and feedback with customers and/or clients in order to support needs and resolve problems
  • Attend weekly/monthly group committees as requested
  • Manage error reports on a weekly basis
  • Communicate activities and progress of assigned committees and teams to appropriate staff
  • Identify and refer members to Case Managementprior to discharge or as deemed appropriate through referral review
  • Participate in IPA grand rounds providing a concise history and overview of the member's progress and discharge plan. Attend any onsite specialty facility rounds as appropriate.
  • Perform on call duties after hours and on weekends as requested and contact facilities regarding patients expected to discharge or be transferred. Assure discharge plans are implemented. Confer with Hospitalist on call as appropriate
  • Travel as needed
  • Other duties as assigned

Required skills:

  • Active & unrestrictive RN licensure in the state of Connecticut
  • 2+ years clinical experience in acute care (i.e., ICU,CCU, ER, med-surg)
  • 2+ years CM or UM experience or related health care experience
  • 2+ years managed care experience
  • Demonstrated knowledge of general PMG/IPA operations
  • Computer literate in Microsoft Word
  • Prior experience managing competing priorities and work under significant time constraints
  • Willingness/ability to be flexible and adaptable of schedule to attend various meetings and/or promotional events
  • Prior demonstrated ability to perform complex problem solving related to health care utilization

Preferred skills:

  • CCM certification
  • Ability to participate in a team environment; supporting and respecting all members and encouraging achievement of group goals
  • Ability to problem solve and make decisions independently
  • Ability to manage competing priorities and work under significant time constraints
  • Ability to synthesize large volumes of information
  • Ability to work effectively with physicians and ancillary staff, communicating both written and verbally
  • Ability to self-motivate with strong quantitative and organizational skills
  • Ability to look at challenges as opportunities
  • Ability to read quickly with excellent comprehension and retention

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

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.

Job Keywords: RN, Registered Nurse, CT, Connecticut, Farmington, internal medicine, family medicine, Adult medicine, utilization management, Medical management, ProMGFarm2019
Associated topics: ambulatory, bsn, coronary, domiciliary, maternal, mhb, nurse, nurse clinical, registed, staff nurse * The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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