Requisition Number: 2197573
Job Category: Nursing
Primary Location: Charleston, WV
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
This role will be performing outpatient clinical coverage review services, which require interpretation of state and federal mandates, applicable benefit language, and consideration for outpatient procedures and services.
If you are located in WV, you will have the flexibility to work remotely* as you take on some tough challenges.
This is a Monday through Friday position during standard business hours in the local time zone. Rotating Saturdays may be required, approximately every 6 to 12 weeks.
- Function as a member of a self-directed team to meet specific individual and team performance metrics
- Ability to communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations
- Telephonic discussion with health care providers and / or members to explain benefit coverage determinations and to obtain additional clinical information
- Act as a resource for others with less experience
- Work independently and collaborating with Medical Directors and non-clinical partners
- Adapt to a highly changing environment and a heavy case load
This position may require active and unrestricted Nursing licensure in multiple US States. Selected candidate must be willing and able to obtain and maintain multiple state licensure. Application fees and filing costs will be paid for by UHG.
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.
Years of post-high school education can be substituted/is equivalent to years of experience
- Active, unrestricted RN license in the state of residence
- Willingness and ability to obtain additional RN licenses if necessary
- 1+ years of experience as a Registered Nurse (RN)
- Demonstrated proficiency in computer skills, i.e., Windows, Instant Messaging, and Microsoft Office including Word, Excel, Outlook and OneNote
- Proven exemplary clinical documentation skills
- Dedicated, distraction-free workspace and access to install secure high-speed internet via cable/DSL/fiber at home
- Bachelor’s degree
- Broad range of nursing experience, i.e., med surg, ICU, ER
- Medicare experience
- Experienced in Medicare, Medicaid and CMS guidelines and regulations
- Background involving utilization review for an insurance company or experience in case management
- Experience in medical necessity review, medical record review, medical record audits
- Experienced in collaborating with physicians and other healthcare professionals
- Familiarity with Milliman Care Guidelines or InterQual
- Knowledge of ICD 10 and CPT coding
- Proven ability to work seamlessly and independently in multiple computer platforms
- Proven ability to be flexible and willing to adapt to an ever-changing environment
- Reside in a compact state
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
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