Preservice Review Nurse RN - Remote- Tennessee

Overview

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 inclusion, talented peers, comprehensive benefits and career development opportunities.

Come make 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.

General Job Profile:

• Generally work is self-directed and not prescribed
• Works with less structured, more complex issues
• Serves as a resource to others

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

• 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

• 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)
• 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
• 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)
• Final Determinations Based on Clinical and Departmental Guidelines
  • Demonstrate understanding of business implications of clinical decisions to drive high quality of care
  • Understa…