Baltimore, Maryland
Sedalia, Missouri, Missouri
Raleigh, North Carolina
Oakwood, Georgia
Spokane, Washington, Washington
Posted: 14-Dec-24
Location: Las Vegas, Nevada
Categories:
Internal Number: 145204687
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 to start Caring. Connecting. Growing together.
When you work with OptumCare, what you do matters. It's that simple…and it's that challenging. In providing consumer - oriented health benefit plans to millions of people, our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.
Regardless of your role at OptumCare, the support you feel all around you will enable you to do what you do with energy, integrity, and confidence. So take the first step in what is sure to be a fast paced and highly diversified career.
The Preservice Review Nurse reviews requests received from providers, using approved protocols and criteria. The Preservice Review Nurse is expected to approve those requests that meet medical necessity, along with benefit level, and the contractual status of the provider / facility as appropriate for Optum Medical Network membership.
You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- 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
- Document of denial, giving attention to details using appropriate platforms, templates, communication processes, etc. (e.g., word, email)
- Make outbound calls to members and/or providers to clarify information
- Communicate determinations to relevant stakeholders, as applicable (providers)
- Take appropriate steps based on case determination by the Medical Director or nurse (e.g., denial upheld, overturned, dismissed,
- pended for additional action)
- Obtain relevant medical records to submit appeals for additional review determinations regarding whether cases should be reopened after determination has been made and route to RN for review
- Contact and work with other internal resources to obtain and clarify information
- Manage case process from start to finish
- Performs all other related duties as assigned
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:
- High School Diploma/GED or higher
- Current unrestricted Nursing License (LVN, LPN)
- 3+ years of clinical experience as an LPN, LVN
- Work experience using MS Word (creating, editing, and saving documents), MS Excel (entering data into spreadsheets), and any email program that includes calendaring (create emails, folders and meeting invites)
- Ability to work in Pacific Time Zone or MTN from 8:30am to 5:00pm with occasional weekends as business needs arise
Preferred Qualifications:
- Experience with utilization review or pre - service review
- Preceptor experience
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, or Washington, D.C. Residents Only: The hourly range for this role is $19.47 to $38.08 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with al minimum wage laws as applicable. 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.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
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.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
