Utilization Management Director jobs in Nevada

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The Manager, Utilization Management Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members.

The Manager is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources. 

If you are located in either Mountain Time Zone or Pacific Time Zone, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Creates and upholds robust policies and procedures for coverage determinations and redeterminations in accordance with CMS guidelines
• Serves as the Medicare coverage determinations and redeterminations subject matter expert
• Writes and maintains department specific job aids/work instructions
• Utilizes available data to forecast, optimize prior authorization staffing, and streamline workflow
• Recruits, onboards, trains, and manages of Medicare PA and Appeals pharmacists and technicians
• Manages contracts with government, state, and other regulatory vendors
• Maintains coverage determination member and prescriber notification letters
• Oversees the draft of Medicare denial verbiage templates
• Actively participates in goal setting and regularly evaluates the performance of the team
• Generates and delivers comprehensive reports on prior authorization to both internal and external stakeholders
• Collaborates with other clinical operations team members as it pertains to utilization management review
• Investigates and resolves escalated issues from clients and clinical partners as needed
• Works with Director, Prior Authorization on other responsibilities, projects, and initiatives as needed
• Adheres to the Capital Rx Code of Conduct including reporting of noncompliance
• Implements and executes policies and processes necessary to support the business need and maintain compliance with regulatory requirements
• Analyzes operational and analytical reports to monitor and track operational efficiency
• Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management
• Additional 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 (RN)
• 2 supervisory or leadership experience
• Utilization Management experience
• Criteria based review experience
• Proficient with Microsoft Word, Outlook and Excel
• Proven solid attention to detail, excellent time management and organizational skills
• Proven excellent communication skills both verbal and written
• Proven ability to work independently under general instructions and with a team
• Proven passionate about contributing to an organization focused on continuously improving consumer experiences
• Proven self-starter with the ability to work in a fast-paced environment with shifting priorities

Preferred Qualifications:

• Bachelor’s degree in nursing (BSN)
• Experience in a team lead/SME or trainer/preceptor role
• Health Plan experience
• Medicare experience
• MCG experience
• Clinical experience in ICU or emergency department
• Experience with managing large remote teams
• Ability to handle 13-17 direct reports

Scheduled Weekly Hours

• 40

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California, Colorado, Nevada or Washington Residents Only: The salary range for this role is $88,000 to $173,200 annually. 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.

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 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.