Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that is improving the lives of millions. Here, innovation is not about another gadget; it is about making health care data available wherever and whenever people need it, safely and reliably. There is no room for error. If you are looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.(sm)

Responsible for the facilitation of the inpatient Utilization Management process including in-network, out of network, case management and discharge planning as well as assisting the Associate Director of Inpatient Management with UM/QM functions as necessary. Acts as a facility liaison to promote cooperation and efficiency between the IPA and the facility.

Primary Responsibilities:

• Directly performs concurrent review
• Accurately identifies and documents level of care
• Coordinates, facilitates and documents comprehensive discharge planning
  • Coordinates in-network services for OON discharges
• Ensures the appropriate utilization of capitated and contracted specialists, providers, facilities, and vendors according to region and risk
• Attends inpatient review rounds and presents cases to medical director(s), health plans and ACMM management staff
• Facilitates OON transfers to In-Network facilities
• Works collaboratively with internal and hospital contract staff
  • Initiates letter of agreement for OON services in a timely manner
  • Provides input for potential contracts
  • Identifies and communicates high dollar / high risk cases
  • Oversees the utilization of contracted facilities and reports OON utilization
• Develops and maintains relationships with both network and Out of Network hospital UM and ER staff
• Works directly with AppleCare Hospitalists to develop and implements inpatient processes including, but not limited to
  • Identification of patients and referral to specialty clinics such as Comprehensive Care (high-risk) Clinic, Anti-coagulation and/or Diabetic Clinic
  • Facilitates and ensures timely communication between PCP and Hospitalists
• Provides direct Case Management activities if necessary
  • Identifies readmit for CM coordinations
  • Identifies Healthy Families and Medi-Cal members for CCS referral and facilitates those referrals
  • Identifies and coordinates high dollar/high risk patients to case management
• Participates in UMC/QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned
• Participates in inpatient UM/QM projects and completes in a thorough and timely manner
• Other duties as assigned which may include weeknight, weekend, and holiday on-call
  

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:

• Active unrestricted California LVN or RN license
• Valid California Drivers license and insurance
• 5+ years experience or above in a Managed Care environment, preferably in an IPA or MSO
• Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifications:

• Thorough clinical knowledge of common inpatient diagnoses
• Understanding of DRGs
• Knowledge of HMO, MSO, and ACO structures and operations.
• Exceptional Microsoft office Word, Excel and internet skills
• Knowledge of standardized CMS, Medicare Advantage, HMO, and Medi-Cal benefits structures
• Solid Organizational skills
• Ability to perform complex problem solving
• Ability to work effectively with physicians
• Solid people skills

Physical Demands

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

Work Environment

• Normal hospital and office environment. May be subject to temperature variations in the office. Occasional early morning, evening or weekend work. Occasional pressure due to multiple tasks, deadlines, high inpatient census, calls or interruptions
  

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care 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.