Utilization Management RN & Coding Specialist

Utilization Management Rn Coder

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Utilization Management RN Coder will accurately and efficiently review and extract pertinent case details from patient medical records; and craft strongly defensible appeal letters per process instructions and the department's/company's guidance. They will have a working knowledge encoder use and selecting appropriate, supportable appeal arguments from evidence-based, peer reviewed medical literature as provided, as well as interpreting and utilizing ICD 9 and 10, CM and PCS, CPT coding system, and HCPCS guidelines. They will recommend changes to coding which will retain, lessen, or increase financial impact when analysis of chart indicates opportunities. They will educate clients on correct coding and compliance for best practices. They will participate in ALJ (Administrative Law Judge) hearings as representatives of the clients during tele-hearings. The Coding Quality Analyst will complete their case within the time expectations while providing high quality reviews. The Appeals nurse will perform their job functions, adhering to both Optum and OPAS policies and procedures, which include but are not limited to the following:

Adheres to approved schedule and arrives to work timely

Maintains accurate accounts of time off in both Verint and HR Direct as per guidelines, and follows directives for time off, schedule changes, etc

Follows directive of composing appeal letters to include appropriate data extraction, construction of well-written appeals letters with proper grammar, utilization of appeal tools including pre-constructed templates, and inclusion of appropriate medical literature references

Use and fluency of encoders, coding clinics, ICD-9 and 10 guidelines, CM and PCS, CPT coding system and HCPCS guidelines

Working knowledge of Word

Effective communication skills

Excellent typing skills with a minimum speed of 45/min

Adheres to company policies and procedures as well as policies, procedures and laws

Understands and comply with HIPAA confidentiality requirements

Support and promote OPAS, Optum, and the enterprise goals and mission

Build relationships across Optum, OPAS, OGA and our clients

Collaborate with peers to assure continuity of communication and execution of deliverables as needed

Adheres to quality and productivity expectations

Participate in and contribute to meetings as appropriate

Maintains organization on the team and ensures everyone conducts themselves professionally

Remains up to date with all learning modules, competencies, and state required licenses

Performs other related duties, tasks, and processes as required by leadership

Ability to establish priorities, be self-motivated, work independently, and follow instructions with supervision and structure

Positive attitude and the ability to function as a collaborative team member

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Associate's degree

Possess one of the following Coding Certifications: CCS, CCS-P, CPC-H, CPC, RHIT, RHIA, CDIP, CCDS

Unrestricted RN license required in state of residence

3+ years of experience in ED, Telemetry, CCU

1+ years of Inpatient Coding experience as a professional coder, OR possession of an active coding certification for a minimum of six (6) months with concurrent inpatient DRG coding experience for at least one year obtained while practicing as a registered nurse

Preferred Qualifications:

Pre-authorization experience

Utilization Management experience

Case Management experience

Knowledge of Milliman Criteria

Certified Case Manager (CCM)

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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 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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

#RPO #GREEN

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