This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description This role plays a critical part in ensuring that patients receive high-quality care while efficiently utilizing medical resources. - Reviews patient medical records to assess the appropriateness and necessity of proposed treatments - Collaborates with healthcare providers and insurance companies to ensure a seamless care experience - Focuses on maximizing patient outcomes and optimizing resource allocation - Utilizes exceptional clinical knowledge and excellent communication skills - Thrives in a fast-paced and ever-changing healthcare environment Qualifications - Associate's Degree in nursing or equivalent combination of education/related experience: Required - Bachelor's Degree in Nursing (BSN): Preferred - Five years' acute hospital experience required with preferred experience in critical care areas: Required - Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required Requirements - Registered Nurse (RN) licensure in the state of practice: Required Essential Functions - Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool - Participates in annual Optum/Inter Qual training required - Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score - Meets weekly productivity metrics within 90 days of completing orientation - Maintains quality audit metrics within 90 days of completing orientation - Completes all required departmental education assigned with timeliness and accuracy - Follows all departmental workflows in communication variances to the on-site care management teams - Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions - Collaborates with healthcare professionals to develop and implement comprehensive patient care plans - Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders - Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices - Performs other job-related duties as assigned Organizational Requirements - Adventist Health is committed to the safety and wellbeing of our associates and patients - All associates must receive all required vaccinations as a condition of employment - Medical and religious exemptions may apply - Adventist Health participates in E-Verify

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Utilization Review Nurse, RN is responsible for providing clinically efficient and effective Inpatient utilization management. Reviews inpatient criteria for acute hospital admissions and concurrent review and or prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all inpatient admission and preauthorization requests from providers that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service or treatment for review with the Medical Director for a decision. The shift is Monday through Friday 8am-5pm in Pacific or Mountain Time Zone. Occasional participation in weekend rotation is required. If you are located in PST or MST, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: - Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes - Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines - Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria - Documents clinical reviews in care management system. Provide accurate and timely documentation and supporting rational of decision in care management system - Utilizes care management system and resources to track and analyze utilization, variances and trends, patient outcomes and quality indicators - Research and prepares clinical information for case review with Physician Leadership for patient treatment and care planning - Utilizes knowledge of resources available in the health care system to assist the physician and patient effectively - Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member’s needs along the continuum of care - Successfully completes the Interrater Reliability Testing to ensure consistency of review and application of criteria - Meets timeliness standards for decision, notification, and prior authorization activities - Serves as an advocate for all providers and their patients - Demonstrates a positive attitude and respect for self and others and responds in a courteous manner to all customers, internal and external - Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding Optum business - Performs other duties as required or requested in a positive and helpful manner to enable the department to achieve its goals 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 unrestricted Registered Nurse (RN) license in state of residence - Ability to obtain Registered Nurse license in the state of California within 90 days of hire - 3+ years of clinical nursing experience in acute care hospital or LTAC setting - 1+ years of Utilization Management experience in hospital or insurance setting - Experience applying Medicare and/or Medicaid guidelines - Experience with Milliman (MCG) or InterQual guidelines - Experience researching and preparing clinical information for case review with Physician Leadership for patient treatment and care planning - Experience providing accurate and timely documentation of clinical review and supporting rational of decision in care management systems - Experience employing analytical skills necessary for quality case management, utilization review, and quality improvement to meet organizational objectives - Experience using various computer software applications with an intermediate level of competence, including Microsoft Word and Excel - Primary residence in Pacific or Mountain time zone and ability to work required hours in PST or MST Preferred Qualifications: - Inpatient Utilization Management experience - Utilization Management experience for insurance or managed care organization - Prior Authorization experience *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy. 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 $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable. 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. UnitedHealth Group 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. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

• Ensure LX technologies are functioning at optimum levels • Manage user access for LX system • Generate reports on compliance and provide insights • Conduct testing and feedback on training content • Collaborate with developers and teams for system related issues

• Work with stakeholders to understand business needs and design technical solutions that will meet quality needs for security, scalability, reliability, usability, and accessibility. • Collaborate with team to develop, test, and implement technical solutions using configurations and customizations in enterprise software systems in an agile development process. • Follow development standards for solution design, development, testing, implementation, and documentation and work with team to continually refine and improve those standards. • Perform testing for solutions to ensure releases meet standards for efficiency, quality, security, and reliability. • Provide maintenance and technical support for enterprise applications in accordance with organizational standards and service-level agreements. • Keep up with industry trends and learn new technologies as needed to meet company needs.