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Utilization Review Nurse - ProHealth Physicians


Last Updated: 6/20/21

Job Description

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)

If you want to get way ahead in your career, it makes sense to be with an organization's that's way ahead of the curve. Formed in 1997, ProHealth Physicians has grown to become Connecticut’s leading primary care physician organization. With over 90 locations throughout the state of Connecticut, our family of primary care doctors and specialists care for more than 360,000 people statewide. In fact, ProHealth serves every county and provides roughly ten percent of the primary care delivered to patients in the state. We're leaders in thinking and in serving our communities. For instance, we're a C.M.S. approved Accountable Care Organization (ACO), covering over 30,000 Medicare patients associated with our community-based primary care providers. We're also nationally recognized as a NCQA Level III Medical Home. That kind of progressive leadership makes us perfect fit for Optum and UnitedHealth Group's expanding family of providers. This is a place where you can stay way ahead as you do your life's best work.(sm)

ProHealth Physicians has an opening for two (2) hospital based Utilization Management Review Nurses to join our team. The hospitals are based in New Haven and Bristol, CT
Primary Responsibilities:
  • Daily rounds, reviewing of medical records, concurrent review, and discharge planning on inpatient, and skilled nursing admissions
  • Prior authorization on Durable Medical Equipment (DME), Home Health services, and Ambulance transport
  • Daily inpatient rounds with hospital staff (Hospitalists and Care Managers)
  • Communicates discharges to the IPA Provider by 12 noon
  • Reviews inpatient cases with Director daily
  • Documents Milliman Guideline(s) on every inpatient case within 24 hours of receipt and updates guideline as hospitalization continues
  • Notifies patient’s Primary Care Physician of admission, discharge and discharge plan within 24 hours of each event as appropriate
  • Analyzes medical cases for appropriateness and plans all phases of care in conjunction with the Hospitalist, attending Physician, Specialists
  • Utilizes the nursing process to establish individual patient goals and measures patients’ response to the plan of care for appropriate outcomes and intervenes appropriately
  • Collaborates with physicians, patients, and families to formulate an optimal plan of care that meets all the medical, psychosocial and financial needs of the patient
  • Explores care options to reduce cost, decrease length of stay, curtail re-admission and influence quality outcomes
  • Understands capitation vs. fee for service
  • Knowledgeable regarding network providers and current contracted specialists
  • Manages cases according to delegation agreement requirements, including notifications regarding LOS >5 days
  • Regularly communicates with Health Plans as appropriate
  • Accurately uses database for daily documentation of clinical information, opportunity days, denied days and levels of care
  • Assists with implementation of all policies and procedures in the group through knowledge and experience
  • Maintains ongoing communication and feedback with customers and/or clients in order to support needs and resolve problems.
  • Communicates activities and progress of assigned committees and teams to appropriate staff
  • Identifies and refers members to Case Management prior to discharge or as deemed appropriate through referral review
  • Participates in IPA Grand Rounds providing a concise history and overview of the member’s progress and discharge plan. Attends any onsite specialty facility rounds as appropriate

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:
  • Current, Unencumbered Connecticut Nursing License
  • Two years of clinical experience in acute care (i.e., ICU, CCU, ER, med surg)
  • One year of Case Management, Utilization Review, Prior Authorization or Pre-Service Review experience
  • Valid Driver’s license and insurance
  • Proficient in Microsoft Office
  • You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role
  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive VoiceResponse (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.

Preferred Qualifications:

  • Bachelors Degree in Nursing - BSN
  • CCM Certification - Certified Case Manager

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

Job Keywords: RN, Registered Nurse, UM Nurse, Utilization Management Nurse, CT, Connecticut, Utilization Review Nurse, Prior Auth, Prior Authorization, Pre-Service Review, Nurse, ProHealth Physicians, UnitedHealth Group, Optum, Hospital Nurse, Case Manager

Company Details

Eden Prairie, Minnesota, United States
Mission We are committed to introducing innovative approaches, products and services that can improve personal health and promote healthier populations in local communities.  Business model From its flexible delivery models to multi-payer strategy, OptumCare® is approaching care in a unique way — unlike anyone else in the marketplace...