Preservice Review Nurse, RN

Job description

As a Telephonic Preservice Review Nurse, you'll perform pre-service clinical coverage reviews for outpatient services that require notification. You'll use benefit plan documents, evidence-based medical policy, and nationally recognized clinical guidelines to determine the medical appropriateness of requested services.

This is a fully remote role; you can work from anywhere within the United States. You'll partner with medical directors and provider teams to deliver timely, accurate determinations that put the member first.

Responsibilities

• Assign cases to the appropriate review team (Medicare, Medicaid, Commercial)
• Research coverage using benefit documents, evidence of coverage, and state & federal mandates
• Prioritize cases by urgency and date of service to meet turnaround times
• Review and interpret clinical and medical records submitted by providers
• Request additional documentation when records are incomplete
• Validate diagnostic, procedure, and service codes for accuracy
• Make coverage determinations in line with relevant clinical protocols

Requirements

• Current, unrestricted RN license in your state of residence
• Multi-state licensure, or willingness to obtain it
• 3+ years of recent RN experience
• Dedicated, distraction-free home workspace with high-speed internet

About Optum

Optum, part of UnitedHealth Group, is a health-services and technology company that connects care, pharmacy, data, and administrative services to improve health outcomes for millions of people. Our teams work remotely across the U.S. to make the health system work better for everyone.