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RN, Preservice Review Nurse - Remote
Lensa
Irvine (CA)
Remote
Full time
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Job summary
Join a leading healthcare organization as an RN, Preservice Review Nurse, where you will perform clinical coverage reviews and utilize your nursing expertise to improve health outcomes. Enjoy flexibility and a supportive work environment focused on health equity.
Benefits
Qualifications
- 2+ years of RN experience in an acute setting.
- Unrestricted, active RN license in California.
Responsibilities
- Perform pre-service clinical coverage review of services.
- Gather clinical information to assess and expedite care needs.
- Communicate with appropriate UM team member as needed.
Skills
Education
Tools
Job description
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Lensa is the leading career site for job seekers at every stage of their career. Our client, UnitedHealth Group, is seeking professionals. Apply via Lensa today!
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.
As an RN, Preservice Review Nurse, you will be 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.
If you have an active, unrestricted RN licensed in state of CA, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities
- Perform utilization and concurrent review using CMS, Medicare, Health plan, and MCG criteria
- Gather clinical information to assess and expedite care needs
- Communicate with appropriate UM team member as needed to troubleshoot difficult or complex cases
- Consistently exhibit behavior and communication skills demonstrating Optum’s commitment to superior customer service, including quality, care, and concern with every internal and external customer
- Select the correct hierarchy level and apply it correctly based on the available medical information
- Meets or exceeds productivity targets while meeting turnaround times
- Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
- Performs additional duties as assigned
Required Qualifications
- Unrestricted, active RN license in the state of California
- 2+ years of RN experience in an acute setting
- Ability to use a PC in a Windows environment, including MS Word
- Undergraduate degree (BSN) or equivalent experience
- Utilization management and prior authorization experience
- Working knowledge of CMS health plan and MCG criteria
- All employees working remotely 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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
- Seniority levelEntry level
- Employment typeFull-time
- Job functionHealth Care Provider
- IndustriesIT Services and IT Consulting
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