Remote Preservice Review Nurse RN – Massachusetts

Optum

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Requisition Number: 2232562
Job Category: Nursing
Primary Location: Boston, MA
(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.  

You’re empowered to do your best by supporting Optum Government Solutions Massachusetts (MA) Long Term Services and Supports (LTSS) Third Party Administration (TPA) program. Supporting the Commonwealth of Massachusetts, the MALTSS TPA program manages several elements of MassHealth’s LTSS program, including prior authorization, provider enrollment and credentialing, program integrity, and quality improvement.  The Preservice Review Nurse RN is responsible for performing pre-service/prior authorization clinical coverage review of Home Health Services and Day Habilitation. Works closely with managers and peers.

If you live in the state of Massachusetts, you’ll enjoy the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Performing pre-service/prior authorization clinical coverage review of Home Health Services and Day Habilitation
  • Review/interpret clinical/medical records submitted from provider
  • Will be responsible in answering provider inquiries/encounters
  • Determine the appropriateness of community services following evaluation of medical guidelines and benefit determination
  • Identify solutions to non-standard requests and problems
  • Participates in regular meetings to collaborate with supporting leadership and team to ensure operational efficiency
  • Assures performance adheres with established quality standards, evidenced based practice guidelines and departmental benchmarks and workflows
  • Act as a resource for others; provide explanations and information on difficult issues
  • Represents the MA MLTSS program in a positive, solution focused manner that embodies our corporate values: Integrity, Compassion, Relationships, Innovation and Performance
  • Minimum 10% travel within the state of MA

What are the reasons to consider working for UnitedHealth Group?   Put it all together – competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

  • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
  • Medical Plan options along with participation in a Health Spending Account or a Health Saving account
  • Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
  • 401(k) Savings Plan, Employee Stock Purchase Plan
  • Education Reimbursement
  • Employee Discounts
  • Employee Assistance Program
  • Employee Referral Bonus Program
  • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

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:

  • Associate’s Degree (or higher) in Nursing
  • Unrestricted RN license in the state of Massachusetts
  • 3+ years of previous clinical and/or Prior Authorization Utilization Management experience
  • Designated workspace and access to install secure high-speed internet via cable or DSL in home

Preferred Qualifications:

  • Reside in the state of Massachusetts
  • Familiarity with Massachusetts Medicaid
  • Previous Day Habilitation experience
  • Previous Home Health Service experience
  • Proficient with Microsoft Office programs, including Word, Excel, PowerPoint
  • Excellent communications skills, including the ability to write clearly, succinctly and in a manner that appeals to a wide audience
  • Excellent time management, organizational, and prioritization skills with ability to balance multiple priorities
  • Able to work independently, self-directed and the ability to be self-starter

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

 

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.