UnitedHealth Group Preservice Review Nurse RN – Remote in TN in Nashville, Tennessee

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. Positions in this family require a current, unrestricted nursing license (i.e. RN) in the applicable state, as indicated in the function description and/or job title. Positions in this function require various nurse licensure and certification based on role and grade level. Licensure includes RN, depending on grade level, with current unrestricted licensure in applicable state. If you are located in Tennessee, you’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: • Assesses and interprets customer needs and requirements • Identifies solutions to non-standard requests and problems • Solves moderately complex problems and/or conducts moderately complex analyses • Works with minimal guidance; seeks guidance on only the most complex tasks • Translates concepts into practice • Provides explanations and information to others on difficult issues • Coaches, provides feedback, and guides others • Acts as a resource for others with less experience Functional Competencies • CPS_Conduct Non-Clinical Research to Support Determinations • 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) • CPS_Review Existing Clinical Documentation • 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 • CPS_Conduct Clinical Research to Support Determinations • 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 policies, Coverage Determination Guidelines [CDG], National Comprehensive Cancer Network [NCCN], state/federal mandates) -Review/interpret other sources of clinical/medical information to support clinical or medical determinations (e.g., previous • diagnoses, authorizations/denials, case management documentation) • Obtain information from patients, providers and/or care coordinators as needed to verify services rendered and/or recommend additional options (e.g., Organization Determination Appeals and Grievance [ODAG], steerage calls) • Apply knowledge of applicable state/federal mandates, benefit language, medical/ reimbursement policies and consideration of relevant clinical information to support determinations • Collaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e.g., Medical Directors and their staff, Optum, UHC, Account Management) • CPS_Make Final Determinations Based on Clinical and Departmental Guidelines • Demonstrate understanding of business implications of clinical decisions to drive high quality of care • Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS, NCQA/URAC accreditation) • Ask critical questions to ensure member- and customer-centric approach to work • Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results • Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes • Use appropriate business metrics to optimize decisions and clinical outcomes • Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up) • CPS_Achieve and Maintain Established Productivity and Quality Goals • Meet/exceed established productivity goals • Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations -Manage/prioritize workload and adjust priorities to meet quality and productivity goals • CPS_Drive Effective Clinical Decisions Within a Business Environment • Ask critical questions to ensure member/customer centric approach to work • Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as needed • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results • Identify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performance • Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, healthcare reform, URAC/NCQA/ERISA/state accreditation) 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. Required Qualifications: • Valid TN RN license • 3+ years of RN experience in an acute setting • Advanced computer proficiency (Microsoft Word, Outlook, and Internet) • Must reside in TN Preferred Qualifications: • 3+ years of experience as an RN in utilization management • All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission. Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employers 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