Remote Preservice Review Nurse PST MST CST Time Zones


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Requisition Number: 2188570
Job Category: Nursing
Primary Location: Cheektowaga, NY
(Remote considered)

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.

Positions in this role are responsible for clinical reviews and require a current, unrestricted RN nursing license in the applicable state. Individual is responsible for performing clinical coverage review of services which require notification or requested pre-determination, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria.

If you are located in PST MST CST time zones, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

  • Perform clinical reviews, which require decision making related to interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
  • Proficient in using clinical criteria and medical policy guidelines
  • Serve as a member of a team with specific individual and team performance metrics
  • Communicate in writing and verbally, all forms of benefit determinations including decisions regarding coverage guidelines, contractual limitations, and reimbursement determinations
  • Manage caseload of Prior Auth Escalations within Lines of Business to ensure care delivery for our members
  • Solid working knowledge of the health insurance industry, products and service and the managed care environment
  • Work independently and collaboratively with Medical Directors and other business partners
  • Flexibility to adapt to changing environment and varied case volume
  • Other duties as assigned by leadership

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:

  • Bachelor’s degree in healthcare, business or related field or equivalent relevant work experience
  • Current unrestricted RN license in the state of residency
  • Able to obtain additional nursing licenses as required
  • Compact license
  • 3+ years RN patient care experience
  • Core understanding of ICD-10 and CPT/HCPCS codes
  • Proficiency working with Microsoft Office Products including Microsoft Outlook (ability to create, edit, save, and send emails), Microsoft Word (ability to create, edit, save, and send documents), and Microsoft Excel (ability to create, edit, save, and send spreadsheets)
  • Proven excellent people skills (i.e.: good communication skills, positive leadership shadow, etc.)
  • Demonstrate exemplary clinical documentation skills
  • Proven ability to communicate clinical determinations objectively and clearly both verbally and in writing
  • Proven self-starter with the ability to handle a fast-paced production environment and multiple review types
  • Proven solid written, verbal, analytic, organizational, time management and problem-solving skills
  • Demonstrated ability to trouble shoot and setup computer equipment independently
  • Flexibility to work outside standard hours of operations due to changing business needs
  • Ability to work an eight (8) hour shift Monday-Friday until 7:00 PM CST
  • Dedicated work area established that is separated from other living areas and provides information privacy
  • Have access to high speed internet (DSL or Cable)

Preferred Qualifications:

  • California RN License
  • Background involving utilization review or experience in case management, or previous experience with clinical claim review
  • Familiarity with utilizing clinical guidelines such as InterQual
  • Solid clinical judgement while applying medical necessity based on approved clinical resources

California, Colorado,  Nevada or Washington Residents Only: The hourly range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $27.07 to $53.08 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy