Utilization Management Review Nurse – RN – OptumCare Network of Connecticut

UnitedHealth Group
October 9, 2021
Atlanta, GA
Job Type


ProHealth Physicians, part of OptumCare, a Division of UnitedHealth Group

$1,000 sign on bonus for all external RN hires

If you want to get way ahead in your career, it makes sense to be with an organization's that's way ahead of the curve. Formed in 1997, ProHealth Physicians has grown to become Connecticut’s leading primary care physician organization. With over 90 locations throughout the state of Connecticut, our family of primary care doctors and specialists care for more than 360,000 people statewide. In fact, ProHealth serves every county and provides roughly ten percent of the primary care delivered to patients in the state. We're leaders in thinking and in serving our communities.  For instance, we're a C.M.S. approved Accountable Care Organization (ACO), covering over 30,000 Medicare patients associated with our community-based primary care providers. We're also nationally recognized as a NCQA Level III Medical Home. That kind of progressive leadership makes us perfect fit for OptumCare and UnitedHealth Group's expanding family of providers. This is a place where you can stay way ahead as you do your life's best work.(sm)

Facilitates cost effective care throughout the continuum utilizing a collaborative multi-disciplinary approach. Implements 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. This includes, but is not limited to: utilization and referral management and total case management, in both the inpatient and outpatient settings.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges

Primary Responsibilities:

  • 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
  • Daily telephonic/inpatient rounds with  hospital staff (Hospitalists and Care Managers)
  • Communicates discharges to  the IPA Provider by 12 noon
  • Reviews inpatient cases with Director on a daily basis
  • Documents Milliman Guideline(s) on every inpatient case within 24 hours of receipt and updates guideline as hospitalization continues
  • Notifies patient’s Primary Care Physician of admission, discharge and discharge plan within 24 hours of each event as appropriate
  • Analyzes medical cases for appropriateness and plans and coordinates all phases of care in conjunction with the Hospitalist, attending Physician, Specialists both in the inpatient and outpatient settings
  • Utilizes the nursing process to establish individual patient goals and measures patients’ response to the plan of care for appropriate outcomes and intervenes appropriately
  • Collaborates 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
  • Explores care options to reduce cost, decrease length of stay, curtail re-admission and influence quality outcomes
  • Understands capitation vs. fee for service
  • Knowledgeable regarding network providers and current contracted specialists
  • Manages  cases according to delegation agreement requirements, including notifications regarding LOS >5 days
  • Regularly communicates with Health Plans as appropriate
  • Understands health plan benefits and contractual information
  • Generates authorizations utilizing principles of UM
  • Accurately uses database for daily documentation of clinical information, opportunity days, denied days and levels of care
  • Follows policy and procedure for Denials and enters this information into the database with 24 hours of the event
  • Assists with implementation of all policies and procedures in the group through knowledge and experience
  • Meets all health plan contract compliance directives for utilization
  • Maintains ongoing communication and feedback with customers and/or clients in order to support needs and resolve problems.
  • Attends weekly/monthly group committees as requested
  • Manages error reports on a weekly basis
  • Communicates activities and progress of assigned committees and teams to appropriate staff
  • Identifies and refers members to Case Management  prior to discharge or as deemed appropriate through referral review
  • Participates in IPA Grand Rounds providing a concise history and overview of the member’s progress and discharge plan.  Attends any onsite specialty facility rounds as appropriate
  • Performs On Call duties as requested
  • Travel as needed
  • Other 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:

  • Registered Nurse
  • 1+ years of CM or UM or related health care experience
  • 1+ years of managed care experience
  • Proficient in Microsoft Office

Preferred Qualifications:

  • BSN
  • CCM Certification
  • 3+ years of CM or UM or related health care experience
  • 3+ years of managed care experience


  • Knowledge of general PMG / IPA operations
  • Strong ability to work effectively with physicians and ancillary staff
  • Excellent communication skills both  written and verbal
  • Ability to perform complex problem solving related to health care utilization
  • Self-motivated with strong quantitative and organizational skills
  • Ability to look at challenges as opportunities
  • Flexible and adaptable of schedule to attend various meetings and/or promotional events
  • Participates in a team environment supporting and respecting all members, encouraging achievement of group goals
  • Able to problem solve and make decisions independently
  • Ability to manager competing priorities and work under significant time constraints
  • Ability to synthesize large volumes of information

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)

Colorado Residents Only: The salary/hourly range for Colorado residents is $53,300 to $95,100 (add additional reference for sales and physicians). Pay is based on several factors including but not limited to education, work experience, certifications, etc. As of the date of this posting, In addition to your salary,  UHG offers the following benefits for this position, subject to applicable eligibility requirements: Health, dental, and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term disability insurance, and long-term disability insurance; business travel accident insurance; Employee Assistance Program; PTO; and employee-paid critical illness and accident insurance.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

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, UM Nurse, Utilization Management Nurse, Telecommute

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