Description

Optum CA is seeking a Outpatient Case Manager to join our team in San Diego, CA. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone.

At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

Reviews contracted Medical Group's authorization requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed decision. Processes all requests within established timeframes. Documents all steps of process in authorization system, utilizes industry standard denial language for denial letters.

The work schedule will be Monday through Thursday 6:30am-5pm

Consideration for remote after 90 day on-site training

This position follows a hybrid schedule with three in-office days per week in San Diego, CA.

Primary Responsibilities:

• Reviews contracted Medical Group's referral requests for medical necessity. Consideration is given to the appropriateness of the setting, place of service, health plan's benefits and criteria of the requested services and utilizes service matrix for contracted providers. Documents process in authorization notes
• Refers all medical necessity denials to the physician for review. Processes denials within establishes timeframes. Documents in the authorization system the denial reason, utilizing the industry standard denial letter language, outlines alternative services available
• Reviews requests within established timeframes for urgent, routine and retro requests to maintain compliance with legislative and accreditation standards
• Obtains additional information for review of appeals. Coordinates with health plan to meet timeframes for expedited appeals

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 school of nursing
• Active, unrestricted Registered Nurse license through the State of California
• 1+ years of experience in case management or utilization review experience in clinical setting
• Proficient with computers and Microsoft windows environment

Preferred Qualifications:

• Bachelor of Science in Nursing, BSN
• 3+ years of experience working in acute care
• HMO experience

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 hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable

OptumCare 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.

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