At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
The Preservice Review RN is responsible for reviewing requests received from providers, using approved protocols and criteria. (Milliman Care Guidelines or Healthcare Operations Protocols). The RN 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 self-funded lines of business. This position is also a resource to new staff and may precept as well.
*** Candidates must be available to work Monday – Friday from 8:00 am – 5:00 pm PST. ***
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Evaluate and assess each request verifying eligibility and specific product
- Determine benefit level based on site of service
- Utilize written criteria to approve, pend or send the case to the medical director for review
- Send cases for pending process when appropriate
- Maintain at least 98% accuracy of clinical review case notes in Facets
- Maintain productivity standards and maintain compliance with all regulatory agencies including NCQA, DOL, DOI for each state, Medicaid, CMS and OPM
- Maintain at least 98% accuracy in summarizing cases for the Medical Director to review using appropriate protocols based members clinical and benefit information
- Maintain compliance with turnaround times based on the member’s product, the type of request and the specific regulatory agency
- Be knowledgeable of and comply with the Nurse Practice Act for each state that licensure is required to perform SHL business
- Precepts / act as a resource for new staff
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:
- A current, unrestricted RN license for the state of Nevada
- 2+ years of recent critical care, ER and/or med-surg nursing experience
- Proficient with Microsoft Word to create, edit, save and send documents
- Proven ability to navigate a Windows environment, Microsoft Outlook, and conduct Internet searches
Preferred Qualifications:
- 2+ years Utilization Management experience in managed care, acute or rehab setting
- Knowledge of utilization review process and prior authorization process in a managed health care industry
- Knowledge of ICD9 / CPT coding and Milliman Care Guidelines
Soft Skills:
- Detail oriented, excellent organizational skills
- Ability to work well under pressure with sound decision making ability
- Excellent written and oral communication skills
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
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.
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.
Clin Coverage Rvw/Prior Author
US-CO-Denver, US-IL-Chicago, US-AZ-Phoenix, US-TX-Houston
