Preservice Review Nurse RN – Remote

For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

Positions in this function require various nurse licensure and certification based on role and grade level.  Licensure includes RN or LPN/LVN, depending on grade level, with current unrestricted licensure in applicable state.  Function is responsible for utilization management which includes Preservice review.  Performs reviews of current elective inpatient or outpatient services.  Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.  *Employees in jobs labeled with ‘SCA’ must support a government Service Contract Act (SCA) agreement.

If you are located in California, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Medical necessity review of any prospective referrals (inpatient, outpatient, home health, injectable medications, and/or DME/Orthotics/Prosthetics). Skilled and competent with the Health Plan’s Evidence of Coverage and Benefits, current MCG guideline application, CMS website navigation, Health Plan contracts; Computer savvy with use of multiple websites
• Consistently and accurately completes all required documentation including but not limited to timely completion of medical necessity review, accurate application of review criteria using the Level of Hierarchy per line of Business (Commercial, Medicare Advantage HMO, Dual Special Needs Plan (D-SNP), and Medi-Cal) and use of Standardized documentation
• Daily collaboration with UM Referral Management team, i.e., Care Coordinators, Care Managers, Managers and Medical Directors
• Communicates authorization or denial of services to appropriate parties and may include patient (or agent), attending / referring physician or facility administration
• Demonstrates accountability and ownership to referrals assigned
• Meets or exceeds productivity targets and Quality Audit compliance
• Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

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:

• Graduate from an accredited school of Nursing
• Current, unrestricted RN license in California
• 2+ years of experience in utilization management or (prior authorization review) nurse

Preferred Qualifications:

• 2+ years of experience in utilization management or (prior authorization review) nurse
• Experience in managed care (HMO)
• Experience working in a metric-driven work environment

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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: OptumCare 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.