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Preservice Review Nurse RN - Remote ID-24514

About the position

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. As a Preservice Review Nurse RN, you will apply plan benefit language and medical policy to the clinical coverage review process, providing clinical and managed care expertise.

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You will enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. In this role, you will perform clinical coverage reviews of services, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information. You will complete approval coverage determinations according to applicable medical policy and guidelines, preparing cases for physician review. As a member of a self-directed team, you will meet specific individual and team performance metrics. Your ability to communicate in writing and verbally will be essential as you explain all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations, and reimbursement determinations. You will also engage in telephonic discussions with healthcare providers and members to explain benefit coverage and medical necessity determinations and to obtain additional clinical information. Additionally, you will act as a resource for others with less experience, contributing to a collaborative team environment.

Responsibilities

  • Perform clinical coverage review of services, interpreting state and federal mandates, applicable benefit language, and relevant clinical information.
  • Complete approval coverage determinations according to applicable medical policy and guidelines.
  • Prepare cases for physician review.
  • Function as a member of a self-directed team to meet specific individual and team performance metrics.
  • Communicate in writing and verbally all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations, and reimbursement determinations.
  • Engage in telephonic discussions with healthcare providers and members to explain benefit coverage and medical necessity determinations and to obtain additional clinical information.
  • Act as a resource for others with less experience.

Requirements

  • A current unrestricted license.
  • Demonstrated proficiency in computer skills - Excel, Microsoft platforms, Outlook, clinical platforms.
  • Proven exemplary clinical documentation skills; critical thinking skills.
  • Designated secure workspace.

Nice-to-haves

  • Undergraduate degree.
  • 2+ years of relevant work experience.
  • 2+ years of RN experience including experience in an inpatient/acute setting.
  • Background involving utilization review for an insurance company or experience in case management.

Benefits

  • Comprehensive benefits package
  • Incentive and recognition programs
  • Equity stock purchase
  • 401k contribution
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