Pharmacy Utilization Management RN - California Remote

UnitedHealth Group; Los Angeles (CA); Remote; Confidential; Full time

Job description

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Position in this function is responsible for the review and evaluation of specialty injectable information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.

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

Primary Responsibilities:

• Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.
• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
• Data gathering requires navigation through multiple system applications.
• Staff may be required to contact the providers of record, vendors, or internal departments to obtain additional information.
• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
• Commands a comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
• Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.
• Condenses complex information into a clear and precise clinical picture while working independently.

Positions in this function require various nurse licensure and certification based on role and grade level. Licensure includes RN or LPN/LVN, depending on grade level, with current unrestricted licensure in applicable state. LPN/LVN roles work under the direct supervision of an RN or MD. Function is responsible for utilization management which includes Concurrent Review (on-site or telephonic Inpatient Care Management). Performs reviews of current inpatient services. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

• Generally work is self-directed and not prescribed.
• Works with less structured, more complex issues.
• Serves as a resource to others.

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