Experienced LTSS Utilization Management, RN - Remote in New Mexico: Join Our Team and Shape the Future of Healthcare

About UnitedHealthcare

At UnitedHealthcare, we're simplifying the healthcare experience, creating healthier communities, and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the healthcare system of tomorrow, making it more responsive, affordable, and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing... together.

Job Summary

We're seeking an experienced LTSS Utilization Management, RN to join our team in New Mexico. As a Senior Utilization Management Nurse, you will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for complex and/or critical issues. This role requires a strong and diverse skillset in relevant areas to drive success. If you're a creative and motivated individual with a passion for healthcare, we encourage you to apply.

Primary Responsibilities

• Functional role is responsible for utilization management of LTSS determinations, oversight on outpatient service requests from a reporting perspective and understanding the criteria for inpatient reviews, including concurrent inpatient reviews
• Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in each situation
• Determines medical appropriateness using medical guidelines and benefit determination
• Solves complex problems and develops innovative solutions
• Ability to oversee and run biweekly meetings for Complex/High Risk members in conjunction with LTSS and Health Services staff
• Reviews work performed by others and, provides recommendations for improvement, including performing annual IRR for LTSS determinations
• Provides explanations and information to others on the most complex issues
• Leverage appropriate clinical terminology when communicating with physicians and other medical professionals
• Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action
• Apply professional judgment, take initiative to follow up, and manage conversations to make sound conclusions/recommendations regarding LTSS patient care or coverage
• Apply information about patient condition and benefit applicability/limitations of coverage to make recommendations

Key Qualifications

We're looking for a highly skilled and experienced LTSS Utilization Management, RN with a strong background in clinical and utilization management. If you have the following qualifications, we encourage you to apply:

• Current, unrestricted independent licensure as a New Mexico Registered Nurse
• 3 years of clinical experience
• 1 year of Utilization Management experience
• 1 year of experience with MS Office, including Word, Excel, and Outlook
• 1 year of experience in HCBS LTSS Care Coordination and LTSS UM Determination
• Background in Managed Care
• Currently reside in New Mexico
• Ability to travel locally up to 10% of the time
• Ability to adhere to a Monday - Friday 8a - 5p MST work schedule

Preferred Qualifications

We're also looking for candidates with the following preferred qualifications:

• Master's degree or higher in clinical field
• InterQual Certified and/or Milliman (MCG) Certified
• MIDAS experience
• Proficient in ICUE and Community Care

About Our Company Culture

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.

Why Join Our Team?

We offer a competitive compensation package, with a salary of a competitive salary. 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. Our company culture is built on the values of Caring, Connecting, and Growing, and we're committed to creating a workplace that is inclusive, diverse, and supportive of all employees.

How to Apply

If you're a motivated and experienced LTSS Utilization Management, RN looking for a new challenge, we encourage you to apply. Please visit our website to learn more about this opportunity and to submit your application.