UnitedHealth Group Telephonic Oncology and Specialty Medication Preservice Review Nurses - Telecommute in Illinois
We're making a strong 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 Oncology or 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.
You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
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.
Current, unrestricted RN license in the state of residence
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
Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses required
Computer proficiency, to include strong data entry skills and the ability to navigate a Windows environment
Access to high speed internet from home (Broadband cable or DSL)
Dedicated workspace for home office set up
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
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
Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
Background in preservice review/utilization review/utilization management
Specialty Medication experience
Certified Case Manager (CCM)
ICD Coding experience or strong knowledge of codes
Medicaid, Medicare, Managed Care experience
A background in managed care
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.
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.
Job Keywords: Oncology, Cancer, Case Manager, Care Coordinator, Utilization Management, Utilization Review, RN, Nurse, Chemotherapy, Infusion, Specialty Medication, National Comprehensive Cancer Network, NCCN, OCN, CCM, telecommute, virtual, work from home
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