Optum

Compensation

Full Description

Job Title: Utilization Management Representative Company Overview: Optum is a leading health services and innovation company dedicated to improving the health system and delivering better care for patients. As part of the UnitedHealth Group family, Optum combines technology, data, and expertise to transform healthcare delivery and management. Our Southern California Physicians Managed Care Services division focuses on providing exceptional managed care solutions to improve patient outcomes and client satisfaction. Role Overview: As a Utilization Management Representative, you will play a critical role in evaluating and managing healthcare services to ensure appropriate care delivery. You will work closely with healthcare providers, patients, and internal teams to review medical necessity and support efficient utilization of resources. What You'll Do: - You will review and assess medical records and treatment plans to determine the necessity and appropriateness of healthcare services. - You will collaborate with physicians, nurses, and other healthcare professionals to facilitate timely and effective care decisions. - You will communicate with patients and providers to explain utilization management decisions and address inquiries. - You will document all case reviews and decisions accurately in compliance with regulatory and company standards. - You will participate in quality improvement initiatives to enhance utilization management processes. - You will stay current with healthcare regulations, policies, and best practices related to utilization management. - You will support appeals and grievance processes as needed. What You Bring: - Minimum of 2 years experience in utilization management, case management, or a related healthcare role. - Strong knowledge of medical terminology, healthcare regulations, and managed care principles. - Excellent communication and interpersonal skills to effectively interact with diverse stakeholders. - Proficiency in electronic medical records (EMR) systems and Microsoft Office Suite. - Ability to analyze clinical information and make sound decisions under pressure. Bonus Points If You Have: - Certification in Case Management (CCM) or Utilization Review (URAC) accreditation. - Experience working within managed care organizations or health insurance companies. - Familiarity with Southern California healthcare providers and networks. - Bilingual skills, particularly in Spanish. What We Offer: - We offer competitive salary and comprehensive benefits including medical, dental, and vision coverage. - We offer opportunities for professional development and career advancement within a growing healthcare organization. - We offer a supportive and inclusive work environment that values collaboration and innovation. - We offer flexible work schedules and remote work options to support work-life balance. - We offer employee wellness programs and resources to promote health and well-being. Ready to Apply? To join our team as a Utilization Management Representative, please submit your resume and cover letter through our careers portal at www.optum.com/careers. We look forward to reviewing your application and exploring how you can contribute to our mission of improving healthcare delivery.