at UnitedHealth Group in Boise, Idaho, United States

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Positions in this function is responsible for timely, accurate medical review, determining if requests for services to be provided to The Group patients meet criteria for coverage based upon medical policies, guidelines, and health plan criteria. Responsible for review of inpatient length of stay for compliance with medical policies, guidelines, and health plan criteria. Based on criteria may refer cases to Medical Director Care Management for further review. Ensures compliance to contractual and service standards as identified by relevant health insurance plans and The Group.

This is performed under the direct supervision of the Medical Director, Care Management. Adheres to policies, procedures and regulations to ensure compliance and patient safety. Participation in Compliance and other important training is a condition of employment.

If you are Compact State License and able to work in Mountain Time Zone, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

+ Provides timely, accurate review of precertification and prior authorization requests, for compliance with applicable medical policies and health plan benefits

+ Provides concurrent medical review of inpatient length of stays to ensure compliance with applicable medical policies and health plan benefits

+ Providing both outpatient and inpatient medical management review as needed, to ensure that patient healthcare requirements and organizational goals are met in a reasonable and medically appropriate manner

+ Ensure communication regarding medical reviews are provided to relevant patients and Providers in a timely manner, and in compliance with contractual agreements

+ Ensures compliance with HIPAA and other applicable company policies and procedures as well as regulatory requirements

+ Identify and address opportunities for quality improvement in all aspects of serving our customers. Assist in planning and implementation of systems changes and procedures to achieve overall organizational objectives

+ Maintain effective communication with management regarding development within areas of assigned responsibilities and performs special projects as required

+ MCG certification within one yea