Are you ready for your next challenge? Discover it here at UnitedHealthcare and help us reinvent the health system. This can be your opportunity to take on a role that helps us offer a higher level of care than you'll find anywhere else. Put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. You will discuss cases with treating physicians and other healthcare professionals to ensure our members receive the proper health services. You will be required to maintain communication with acute long term care, acute rehabilitation, or skilled nursing facilities in order to help patients through their care plan. This is an exciting opportunity at a truly inspired organization. Join us. This can be the start of your life's best work.(sm)
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 all fully-funded lines of business. This position is also a resource to new staff and may precept as well.
- 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
- Pend cases by documenting in the claim's payment system, contacting the provider for the necessary information via fax and / or phone and sending a letter to the member to alert them of the pending decision
- Maintain 100% 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 100% 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 resource for new staff
This is an office based role located at 2716 N Tenaya in Las Vegas, NV.
- A current, unrestricted RN license for the state of Nevada
- 2+ years of nursing experience (at least 2 of the following: M/S, Critical Care, ER, surgical)
- Proficient with Microsoft Word to create, edit, save and send documents. Ability to navigate a Windows environment, Microsoft Outlook, and conduct Internet searches
- 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
Careers at UnitedHealthcare Employer & Individual. We all want to make a difference with the work we do. Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine. Here, you get that opportunity every day. As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives. You'll help write the next chapter in the history of health care. And you'll find a wealth of open doors and career paths that will take you as far as you want to go. Go further. This is your life's best work.(sm)
**PLEASE NOTE** The sign on bonus is only available to external candidates. Candidates who are currently working for a UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time, or per diem basis (“Internal Candidates”) are not eligible to receive a sign on bonus.
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: Registered Nurse, RN, Nurse, Prior Authorization, Concurrent Review, Managed Care, Utilization, Utilization Management, Prior Auths, Care Management, Milliman, Interqual, Appeals, Denials, UR, UM, UHC, UnitedHealthcare, UHG, Las Vegas, NV, Nevada