Job was saved successfully.
Job was removed from Saved Jobs.

Job Details


UnitedHealth Group

Specialty Medication Preservice Review Nurse RN - Telecommute in Nebraska (15820739)

Healthcare

All

Yearly

No

Omaha, Nebraska, United States

$3500 Sign on Bonus for External Candidates!!

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

We’re making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that’s driving the health care industry forward. As a Telephonic Specialty Medication Preservice Review Nurse, you will be 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 outpatient services following evaluation of medical guidelines and benefit determination. Ready for a new path? Apply today!

This position is work at home. Work schedule expectations offer some flexibility with a combination of day and consumer hours. Some evening and weekend hours will be required.

If you are located in Nebraska, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial)
  • Validate that cases/requests for services require additional research
  • Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources)
  • Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
  • Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
  • Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
  • Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
  • Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs)
  • Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
  • Apply understanding of medical terminology and disease processes to interpret medical/clinical records
  • Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
  • Review care coordinator assessments and clinical notes, as appropriate
  • Identify relevant information needed to make medical or clinical determinations
  • Identify and utilize medically accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical
  • This position will require active and unrestricted Nursing licensure in multiple US States. Selected candidate must be willing and able to obtain and maintain multiple state licensure. (Application fees and filing costs paid for by UHG)

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 in the state of Nebraska
  • Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses
  • 3+ years of recent experience in a hospital setting, Acute Care, Direct Care experience or experience a Telephonic Case Manager/Utilization Preservice for an insurance company
  • Computer proficiency, to include solid data entry skills and the ability to navigate a Windows environment
  • Access to high-speed internet from home (Broadband cable, Fiber or DSL)
  • Dedicated workspace for home office set up
  • Currently reside in Nebraska
  • Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifications:

  • BSN
  • Compact RN license
  • Background in preservice review/utilization review/utilization management/Prior Authorizations
  • Specialty Medication experience
  • Experience working with ICUE
  • Experience working with prior authorizations for medications
  • ICD Coding experience or solid knowledge of codes
  • Background in managed care
  • Demonstrated problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  • Proven ability to communicate complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

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

**PLEASE NOTE** The sign on bonus is only available to external candidates. Candidates who are currently working for a UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time, or per diem basis (“Internal Candidates”) are not eligible to receive a sign on bonus.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.