Remote Preservice Review RN, NV

Optum

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Requisition Number: 2175170
Job Category: Nursing
Primary Location: Las Vegas, NV
(Remote considered)

**Must be able to work 8am to 5pm work schedule in the Pacific Time Zone**

 

Schedule includes rotating 1 weekend (Saturday and Sunday) every 8 to 10 weeks. You will have one day the week prior and the week after for a regular 5 day work week. 

 

For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life’s best work.(sm)

 

The Preservice Review Nurse is responsible for performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria.  Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination and the contractual status of the provider/facility as appropriate for Optum Medical Network membership.

 

Primary Responsibilities:

  • 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
  • Work independently and collaborating with Medical Directors and non-clinical partners
  • Adapt to a highly changing environment and a heavy case load

 

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:

  • Current unrestricted RN license or Compact in the state of Residence
  • 3+ years of experience as a Registered Nurse (RN)
  • 3+ years of RN clinical experience in a hospital inpatient/acute care setting
  • Demonstrated proficiency in computer skills – Windows, Instant Messaging, Microsoft Suite including Word, Excel and Outlook
  • Proven exemplary clinical documentation skills; critical thinking skills
  • Access to install secure high-speed internet (minimum speed 1.5 download mps & 1 upload mps) via cable / DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement)

 

Preferred Qualifications:

  • Bachelor’s Degree or higher
  • Broad range of nursing experience – med surg, ICU, ER
  • Experienced in Medicare, Medicaid and CMS guidelines and regulations
  • Experience in medical necessity review, medical record review, medical record audits
  • Experienced in collaborating with physicians and other healthcare professionals
  • Background involving utilization review for an insurance company or experience in case management
  • Knowledge of ICD 10 and CPT coding
  • Familiarity with Milliman Care Guidelines or Interqual
  • MST or PST Location

 

Careers at OptumCare. We’re on a mission to change the face of health care. As the largest health and wellness business in the US, we help 58 million people navigate the health care system, finance their health care needs and achieve their health and well-being goals. Fortunately, we have a team of the best and brightest minds on the planet to make it happen. Together we’re creating the most innovative ideas and comprehensive strategies to help heal the health care system and create a brighter future for us all. Join us and learn why there is no better place to do your life’s best work.(sm)  

 

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

 

California, Nevada, or Washington Residents Only: The hourly range for California, Nevada, or Washington residents is $27.07 to $53.08. 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.