Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)Primary Responsibilities:Adhere to and maintain required levels of performance in both accuracy and productivityUnderstand clinical guidelines and associated CMS policiesProvide documentation feedback as neededMaintain up-to-date knowledge by reviewing materials disseminated/recommended by the QM Manager, Operations Managers, Training Managers, and Director of Training/Quality Management, among othersParticipate in department meetings and educational eventsAssure delivery of staff education and trainingUnderstand, articulate and implement best practices related to his area of expertiseProvide guidance on how his area of capability can resolve an organizational need and actively participate in all phases of utilization reviewAssist the development, testing and implementation of technical solutions and validates that the final product satisfies the defined requirementsParticipate in quality improvement initiatives focusing on client satisfactionParticipate in the local auditing processEnsure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)Demonstrate understanding of business implications of clinical decisions to drive high quality of careIdentify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as neededIdentify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performanceIdentify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomesIdentify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as neededCollaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e.g., Medical Directors and their staff, Optum, UHC, Account Management)Comply with the administrative or non-administrative duties and instructions given from time to time by the Company through its authorized representatives either through direct written order or by oral assignmentParticipate in meetings and education conferences to maintain skills and accuracyServe as the point person in escalated mattersDemonstrate willingness and flexibility in working additional hours or changing hoursDemonstrate thorough understanding on how position impacts the project/hospital and organizationBe customer-centric focused and exhibit superb customer service skillsReview technical documentation, such as user guides, training manuals and system specifications, prior to distribution to end-users and ensures his subject area is accurately representedSupply source materials, reference items, and supplemental resourcesContribute core content and original materials and suggests exercises and/or case studies to reinforce learningArticulate and communicate information effectively to diverse audiencesWork collaboratively as a team member to ensure company mission and values are incorporated into team cultureDemonstrate willingness and flexibility in working additional hours or changing hoursAssist with other ad hoc responsibilities deemed necessary by his/her supervisorsRequired Qualifications: Active USRN LicenseGraduate of Nursing with active PHRN licenseMinimum 1 year of Utilization/case Management experienceProficient in computer skills - Windows, IM, Microsoft Office Suite, Outlook, clinical platformsPreferred Qualifications:At least 1 year of clinical experienceUtilization/Case Management experience in a BPO/HMO settingExperience as a trainer/SMECareers 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: Optum is an Equal Employment Opportunity 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.Optum is a drug-free workplace. © 2020 Optum Global Solutions (Philippines) Inc. All rights reserved.Job Keywords: SME, Subject Matter Expert, Nursing, Prior Authorization, Utilization Management, Case Management, USRN, US Registered Nurse, US Nurse, United States Nurse, United States Registered Nurse, Philippine Registered Nurse, Nurse, PHRN, PH RN, PH Registered Nurse, Registered Nurse, RN, Taguig City, Quezon City, Alabang, Muntinlupa City, NCR, National Capital Region
