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Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

Under the direction of a Registered Nurse, this position is responsible for ensuring the continuity of care in both the inpatient and outpatient settings utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates a continuum of patient care utilizing basic nursing knowledge, experience, and skills to ensure appropriate utilization of resources and patient quality outcomes. Fields care management calls after hours or during holidays and logs all calls and actions taken. Reports findings to the Inpatient Manager in a timely manner.

Primary Responsibilities:

• Consistently exhibits behavior and communication skills demonstrating Optum’s commitment to superior customer service, including quality, care, and concern with every internal and external customer
• Implements current policies and procedures set by the Care Management department
• Conducts telephonic prospective, concurrent review of active patient care, and enters Observation, inpatient and SNF authorization as determined through the MCG guideline and Medicare respectively
• Coordinates patient diversion from Emergency department to skilled nursing facility or home with home health per hospitalist determination
• Acts as patient care liaison and initiates pre-admission discharge planning by screening for patients who are high-risk, fragile or scheduled for procedures that may require caregiver assistance, placement, or home health follow-up
• Responds to customer calls regarding the intent to admit, discharge or transfer patient to a contracted facility or higher level of care
• Bridges and completes any outstand emergent cases outstanding after normal working hours and issues requested authorizations for home health, social services, transportation, etc., to maintain continuity of care
• Communicates authorization or denial of services to appropriate parties. Communication may include patient (or agent), attending/referring physician, facility administration, and Optum claims as necessary
• Attends all assigned Care Management Committee meetings and reports on patient status as defined by the region
• Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through the utilization of appropriate reports such as Health Plan Eligibility and Benefits, Division of Responsibility (DOR), and Bed Days
• Ensures appropriate utilization of medical facilities and services within the parameters of the patient’s benefits and/or CMC decisions. This includes appropriate and timely movement of patients through the various levels of care
• Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients, and families
• Provides accurate information to patients and families regarding health plan benefits, community resources, specialty referrals and other related issues
• Initiates data entry into IS systems of all patients within the parameters of Inpatient Concurrent Review Care Management policies and procedures. Maintains accurate and complete documentation of patient information received, including LOC, CPT code, ICD-9, referral type, date, etc.
• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

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:

• Graduation from an accredited Licensed Vocational Nurse program
• Current LVN license in California
• 1+ years of recent clinical experience working as an LVN/LPN

Preferred Qualifications:

• 2+ years of care management, utilization review or discharge planning experience
• Experience in an HMO or experience in a Managed Care setting

California Residents Only: The hourly range for this role is $19.47 to $38.08 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. 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.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.   

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

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