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UnitedHealth Group RN Clinical Review Nurse - Golden, CO in Golden, Colorado

Opportunities with New West Physicians. Bring your passion for health care to New West Physicians in Colorado, a team committed to providing excellent service to every patient… every time. We’re not only one of the largest physician groups in Colorado with 21 offices throughout the Denver Metro area - we’re also part of Optum, a nationwide family of nearly 45,000 dedicated physicians working together to help people live their healthiest lives. That means we’re backed by the resources of a global health care organization working to help people live healthier lives and help make the health system work better for everyone. For four consecutive years, New West Physicians achieved Elite status - the highest ranking - in the America’s Physician Groups Standards of Excellence Survey. In addition, New West Physicians was selected as one of the 2017 Million Hearts® Hypertension Control Champions by the Centers for Disease Control and Prevention, and was the 2015 recipient of AMGA's National Acclaim Award recognizing high performing medical groups bringing the American health care system closer to the ideal delivery model: one that’s safe, effective, patient-centered, timely, efficient, and equitable. It’s all possible because of our highly qualified, board-certified family practice and internal medicine physicians, hospitalists, cardiologists, gastroenterologists, psychiatrists, endocrinologists, neurologists, physician assistants, nurse practitioners and more. If this sounds like the place for you, it’s time to take a closer look at New West Physicians and discover a path to your life’s best work.(sm)

The RN Clinical Review Nurse practices within the scope of the Colorado Nurse Practice Act and in partnership with New West physicians to provide clinically efficient outpatient utilization management. The RN utilizes managed care principles and sound nursing judgment in the coordination, development, implementation and evaluation of interdisciplinary plans of care. Reviews and applies hierarchy of criteria to all outpatient referral and preauthorization requests from the PCPs and specialists that require a medical necessity determination. All cases in which the RN is not able to make a determination on the medical appropriateness of a procedure, service or treatment being requested, the RN will prepare and present the case to the Medical Director for a decision.

Primary Responsibilities:

  • Authorize healthcare services in compliance with contractual agreements, health plan guidelines and medical necessity criteria

  • Maintain clinical expertise and maintain knowledge of scientific progress in nursing and medical arena and incorporate this information into the review and case management processes

  • Maintain logs and proper documentation of cases reviewed, case management activities and the rationale for decisions

  • Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively

  • Successfully complete the Interrater Reliability Testing to ensure consistency of review and application of criteria

  • Serve as an advocate for all IPA physicians and their patients

  • Other responsibilities 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:

  • Active, unrestricted RN license in the state of Colorado

  • Associate’s degree or higher

  • 3+ yrs. clinical nursing experience

  • Microsoft Office proficiency

  • 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 requiredto screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (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:

  • Experience in utilization review, case management and/or managed care a plus

  • Knowledge of CPT and ICD-10 coding a plus

  • Quality improvement experience a plus

Proof of immunity to vaccine-preventable diseases is an employment requirement.

© 2019 OptumCare. All rights reserved.

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both its owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine provided by the medical practices of any of their physicians.

Diversity creates a healthier atmosphere: OptumCare and its affiliated medical practices are 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 and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.