Job Description

Welcome to one of the most challenging and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.(sm)

The Case Managers provides various clinical capabilities within Case Management, Utilization Management, Clinical Coverage or Preservice, Medical Claims and Appeals review. The nurse helps members perform self-care, reduce cost, and improve quality of life through education, empowerment, support, and advocacy. Collaborate and refer to Interdisciplinary team when necessary. Responsible for performing clinical coverage review of services that require notification; determines medical appropriateness of inpatient and outpatient services, concurrent Review (telephonic Inpatient Care Management), evaluating medical claims and appeals following application of medical guidelines and benefit determination adhering on state specific requirements in performing clinical review with sound clinical judgement to obtain correct clinical decision outcome. Utilizes appropriate clinical resources, guidelines, which include, but are not limited to U.S. state and federal mandates, national and local coverage determination, applicable internal UnitedHealth care medical policies and coverage determination guidelines, such as Milliman and InterQual.

Primary Responsibilities:

* Conduct Clinical and Non-Clinical Research to Support Determinations
* Calls members to enroll on specific programs available
* Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
* Identify and utilize medically accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical policies, Coverage Determination Guidelines [CDG], state/federal mandates) and follow based on the hierarchy of review
* Achieve and Maintain Established Productivity and Quality Goals
* Make Final Determinations Based on Clinical and Departmental Guidelines
* Drive Effective Clinical Decisions Within a Business Environment
* Additional duties may apply

*** ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***

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:

* Valid, active and unrestricted US RN license (NCLEX)
* Florida RN Reciprocity or Florida State license
* 1+ years of experience in a hospital, clinical setting or healthcare company
* Proficiency with the Microsoft Office Suite (Word, PowerPoint, Excel - create/edit/save documents, and Outlook- email and calendar management)
* This position is full-time (40 hours/week) Monday- Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of (7:00am - 6:00pm). It may be necessary, given the business need, to work weekends and/or occasional overtime
* Professional proficiency in English and Spanish
* You will be asked to perform this role in an office setting or other company location.
* Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.

Preferred Qualifications:

* BPO (Business Process Outsourcing) experience related to Clinical Case Management and or Clinical Utilization Management
* Experience working with Medicare and/or Medicaid Services

Helping create positive customer experiences for our members can drive your sense of impact and purpose. Join us as we improve the lives of millions. Learn more about how you can start doing your life's best work.(sm)

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system 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, NCLEX RN, Clinical, Utilization, Case Management, Optum, San Juan, Puerto Rico