Preservice Review Nurse RN - Remote

Join to apply for the Preservice Review Nurse RN - Remote role at reputed company Join to apply for the Preservice Review Nurse RN - Remote role at reputed company reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health reputed company 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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. We’re making a solid reputed company between exceptional patient care and outstanding career opportunities. The result is a culture of performance that’s driving the health care industry reputed company. As a Telephonic Specialty Medication Preservice Review Nurse you will be 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 outpatient services following evaluation of medical guidelines and benefit determination. reputed company for a new path? Apply today! This position will require active and unrestricted Nursing licensure in multiple US States. Selected candidate must be willing and reputed company to obtain and maintain multiple state licensure. (Application fees and filing costs paid for by UHG) You’ll enjoy the flexibility to work remotely

• from reputed company reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities

• Determine that the case is assigned to the appropriate team for review (e.g., Medicare, reputed company, reputed company)
• 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)
• 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 reputed company, 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
• reputed company 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
• Identify relevant information needed to reputed company medical or clinical determinations
• Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical

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 reputed company development for other roles you may be interested in.

Required Qualifications

• reputed company, unrestricted RN license in your state of residence
• Multiple state licensure (in reputed company to Compact License if applicable) or ability to obtain multiple state nursing licenses
• 3+ years of recent RN experience
• Computer proficiency, to include proficient data entry skills and the ability to navigate a reputed company environment
• Distraction free, Dedicated workspace with reputed company to high-speed internet from home (Broadband cable, Fiber, or DSL)

Preferred Qualifications

• BSN
• Compact RN license
• Experience working with ICUE
• Experience working with prior authorizations for medications
• ICD Coding experience or solid knowledge of codes
• Specialty medication experience
• Background in preservice review/utilization review/utilization management/Prior Authorizations
• Background in managed care
• TN reputed company
• reputed company employees working remotely will be required to adhere to reputed company’s Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In reputed company to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purch Apply tot his job Apply To this Job