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Responsible for all activities associated with Utilization Management (UM) programs. Ensures all UM activities are efficient, effective and meet regulatory requirements. Monitors staff performance provides mentorship and recognizes and manages departmental opportunities that impact outcomes.

If you are able to work PST zone, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer services with each internal and external customer

• Supervises Nurse Reviewers including selection, training, and performance evaluation, and manages schedules to maintain adequate operations

• Works in conjunction with other UM Referrals Supervisors and Manager to ensure consistency of the referral process across regions and to develop additional processes to ensure success

• Ensures that appropriate Optum Policies and Procedures relating to referrals are adhered to

• Achieve and maintain compliance by supporting the team to reach and sustain processing Commercial, Senior and Medi-Cal LOB referrals within TAT requirements, standardized documentation template application with QA scoring of 98-100%

• Monitors attendance and productivity levels of Nurse Reviewers routinely. Ensure all teammates adhere to organization productivity metrics, quality audits and the daily volume is processed and completed timely

• Services as subject matter expert in referral management programs and processes

• Functions as a key resource to Nurse Reviewers. Will provide guidance and coaching teammates

• Supports and guides staff to be accountable in decision making

• Develops tools and ensures resources are available to support accountable decision making

• Attends meetings as necessary to provide input and obtain information and communicates results appropriately

• Participates in continuous quality improvement of the referral process by analyzing processes and identifying areas where improvements are needed. Initiates necessary steps to make changes when appropriate

• Maintains professional relationships as appropriate with specific health plans, area hospitals and providers

• Works cooperatively with other departments

• Participates in meetings as delegated

• Communicates all issues and concerns as appropriate to their regional VP/Director of Utilization Management

• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

• Performs additional 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:

• Graduate from an accredited school of Nursing

• Current, unrestricted RN or LVN license in California

• 2+ years of experience in referrals, utilization management experience

• HMO Experience

• General knowledge of medical terminology and ICD-10 and CPT/HCPCS coding

Preferred Qualifications:

• Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college

• 2+ years of experience in a leadership role

• Experience in managed care

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $88,000 to $173,200 annually. 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.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.