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 togetherThe Bariatric Prior Authorization RN Case Manager is responsible for clinical operations and medical management activities across the continuum of care for members seeking Bariatric surgery. This will include performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness services following evaluation of medical guidelines and benefit determination. Ready for a new path? Apply today!The required schedule is Monday through Friday: 4 days 8:00am to 5:00pm and 1 day 11:00am to 8:00pm.Primary Responsibilities:Makes outbound calls to assess members' current health status
Case Manages members in the pre-operative and post-operative phases of Bariatric surgery to ensure a positive outcome
Identifies gaps or barriers in treatment plans and coordinate ongoing care with providers
Provides patient education to assist with self-management and healthy lifestyle changes
Stays connected with members to help them stay on the right track regarding diet and weight loss goals
Documents and tracks progress from initial assessment through post-operative care
Interacts with Medical Directors on challenging cases
Makes 'post operation' calls to ensure that discharged member receives the necessary services and resources
Prioritizes cases based on appropriate criteria (e.g., date of service, urgent, expedited)
Ensures compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
Reviews/interprets clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
Identifies missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
Makes determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
Reviews care coordinator assessments and clinical notes, as appropriate
Identifies relevant information needed to make medical or clinical determinations
Identifies and utilizes medically accepted resources and systems to conduct clinical research (e.g., clinical notes, client criteria)
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:
Current, unrestricted RN license in your state of residence
Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses
3+ years of experience in a hospital setting managing medical/surgical, ICU, bariatric patients, or complex case management
Intermediate level of proficiency with Microsoft Word, including the ability to navigate a Windows environment
Ability to work until 8:00pm at least one night per week
Access to high-speed internet from home (Broadband cable, DSL or Fiber)
Designated workspace from home
Preferred Qualifications:
Bachelor's Degree
Certified Case Manager (CCM)
Compact/Multi-State RN license
Bariatric experience as the main focus of your job
Prior Authorization/Utilization Management/Review experience
Post-surgical experience
Patient education experience
Discharge planning experience
Case Management/Care Coordination experience
Managed care background
Knowledge of Milliman (MCG) or InterQual criteria
Reside in a compact license state with a compact license
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.
