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Registered Nurse RN Preservice Review Compact Lics

2 months ago

Detroit, United States UnitedHealth Group Full time

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.

Purpose of Job: Positions in this role are responsible for Women’s Health/ Gender Dysphoria/ Genetics clinical reviews and require a current, unrestricted RN nursing license in the applicable state. Individual is responsible for performing pre-service clinical coverage review of outpatient Women’s Health/ Gender Dysphoria/ Genetics services which require notification or requested pre-determination, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria.

If you have a compact lics and is located from anywhere within the U.S., you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

  • Perform clinical reviews, which require decision making related to interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information

  • Ability to make appropriate clinical decisions within a business environment

  • Serve as a member of a team with specific individual and team performance metrics

  • Communicate in writing and verbally, all forms of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations

  • Work independently and collaboratively with Medical Directors and other business partners

  • Flexibility to adapt to changing environment and varied case volume

  • Other duties as assigned by leadership

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 residency

  • 3+ years of RN patient care experience

  • Proficiency working with Microsoft Office Products including Microsoft Outlook (ability to create, edit, save, and send emails), Microsoft Word (ability to create, edit, save, and send documents), and Microsoft Excel (ability to create, edit, save, and send spreadsheets)

  • Demonstrated ability to objectively and clearly communicate clinical determinations both verbally and in written

  • Demonstrated exemplary clinical documentation skills

  • Proven self-starter with the ability to handle a fast-paced production environment and multiple review types

  • Proven solid written, verbal, analytic, organizational, time management and problem-solving skills

Preferred Qualifications:

  • Bachelor's degree

  • RN License in an NLC (Nurse License Compact) state or the ability to apply and meet requirements for one

  • Professional coding certification and/or core understanding of ICD-10 and CPT/HCPCS codes

  • Women’s Health/ Gender Dysphoria/ Genetics experience

  • Background involving utilization review or experience in case management, or previous experience with clinical claim review

  • Familiarity with utilizing clinical guidelines (i.e.; Medicare, state, MCG or InterQual)

  • Proven solid clinical judgement while applying medical necessity based on approved clinical resources

*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 $28.03 to $54.95 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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: 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.