Preservice Review Nurse - PST time zone - Remote

UnitedHealth Group•Las Vegas, NV

4d•Remote

About The Position

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.

Requirements

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

Nice To Haves

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
Detail oriented, excellent organizational skills
Ability to work well under pressure with sound decision making ability
Excellent written and oral communication skills

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%25 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%25 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