USRN with Prior Authorization Experience | Day 1 HMO

ROLE AND

RESPONSIBILITIES

Function is responsible for 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 inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Conduct Non-Clinical Research to Support Determinations. Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan)

Review Existing Clinical Documentation. Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)

Make Final Determinations Based on Clinical and Departmental Guidelines. Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation)

Achieve and Maintain Established Productivity and Quality Goals. Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations. Your role is critical in allowing our members, families, facilities and health professionals to have greater confidence in the exceptional care we provide. And for you, an everyday opportunity to do your life’s best work.SM.JOB

QUALIFICATIONS

• Valid and unrestricted USRN and PHRN licenses are required
• A minimum of 1 year of hospital bedside nursing experience is required
• At least 1 year of Prior Authorization Review Nurse experience is required
• Clinical competence in understanding hospital care and care coordination
• Knowledge in computer navigation

WHAT WE OFFERMarket Total Rewards Package

Retirement Plan

• Medical Plan (HMO) from Day 1 of employment
• Dental, Medical, and Optical Reimbursements

Life and Disability Insurance

Paid Time-Off

Benefits

Sick Leave Conversion

Tuition Fee Reimbursement

Employee Assistance Program (EAP)Annual Performance Based Merit Increases

Employee Recognition

Training and Staff Development

Employee Referral Program

Employee Volunteerism Opportunity

All Mandatory Statutory

Benefits

• WHO WE AREOptum is the health care technology and innovation company of the United
• Health Group enterprise along with United

Healthcare. United

Health Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone. We’re a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center. As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world. Elevate your career with a leading health care company while improving lives. Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that’s dedicated to Caring. Connecting. Growing together