Radiation Oncology Preservice Review Nurse RN – Remote

Overview Requisition number: 2353367 — Nursing role with Optum. Telephonic Oncology Preservice Review Nurse performing pre-service clinical coverage reviews of services requiring notification, using benefit plan documents, evidence-based medical policy and clinical guidelines to determine medical appropriateness of outpatient services. This is a work-from-home position with a full-time schedule and some flexibility, including a combination of day and consumer hours; evenings, holidays and weekend hours may be required.

Core schedule is daytime hours with occasional evenings and weekends based on business needs. Primary Responsibilities 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, urgency, 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 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 (e.g., approval, denial, 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 references) This position requires active and unrestricted nursing licensure in multiple US states; selected candidate must be willing and able to obtain and maintain multiple state licensure (application fees and filing costs paid by UnitedHealth Group) Required Qualifications Current, unrestricted RN license in your state of residence Ability to obtain licensure in other states as needed 2+ years of Radiation Oncology experience as a nurse Computer proficiency, including solid data entry skills and the ability to navigate a Windows environment Access to high-speed internet from home (Broadband, Fiber or DSL) Dedicated workspace for home office setup Ability to work the schedule listed Preferred Qualifications OCN Certification Chemo/Bio Certification Certified Case Manager (CCM) 7+ years of Radiation Oncology experience ICD coding experience or solid knowledge of codes NCCN experience Background in preservice review/utilization review/utilization management All employees working remotely will be required to adhere to UnitedHealth Group’s telecommuter policy. UnitedHealth Group is an Equal Employment Opportunity employer and maintains a drug-free workplace. #J-18808-Ljbffr