RN, Preservice Review Nurse - Remote

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

We’re making a solid 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 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! You’ll enjoy the flexibility to work remotely * 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