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Radiation Oncology Preservice Review Nurse RN
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At UnitedHealth Group, we're committed to helping people live healthier lives and making the health system work better for everyone. As a Telephonic Oncology Preservice Review Nurse, you'll play a critical role in ensuring that patients receive the best possible care.
About the RoleThis is a full-time, work-from-home position that requires active and unrestricted nursing licensure in multiple US states. You'll be responsible for performing pre-service clinical coverage reviews of services that require notification, using applicable benefit plan documents, evidence-based medical policy, and nationally recognized clinical guidelines and criteria.
Key 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)
- Current, unrestricted RN license in your state of residence
- Ability to obtain licensure in other states as needed
- 2+ years of Radiation Oncology experience as a Nurse
- 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
- Ability to work schedule listed
- OCN Certification
- Chemo/Bio Certification
- Certified Case Manager (CCM)
- 7+ years of Radiation Oncology experience
- ICD Coding experience or solid knowledge of codes
- NCCN experience
- Background in preservice review/utilization review/utilization management
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.
