Preservice Review Nurse RN, Telecommute (Tennessee)

The Pre-Service Review Nurse primary responsibilities:

• Perform utilization and pre-service review using CMS Guidelines, MCG criteria, UHC policies, and State mandates  


• Conduct Prior Authorization Request assessments for DME, medical procedures and services 


• Conduct clinical chart assessments


• Discuss cases with treating physicians and other healthcare professionals to better understand plan of care


• Identify and evaluate delays in care


• Initiate a discharge planning and readmission prevention plan when applicable


• Approve bed days for inpatient cases when applicable based on MCG guidelines


• Arrange alternative care services; Contact and maintain communication with acute long term care, acute rehabilitation, or skilled nursing facilities to move patients through the care continuum


• Gather clinical information to assess and expedite care needs following company policies


• Maintain appropriate legal documentation within operating platform


• Consult with the Medical Director as needed to troubleshoot difficult or complex cases


• Participate in telephonic (WebEx) and in-person staff meetings, and UHC U-learns (on-line learning)

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 17 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.SM

Required Qualifications:

• Active, unrestricted RN licensure in the state of Tennessee


• 2+ years experience in an acute care setting 


• Proficient level of experience in Microsoft Office applications (Word, Excel, Outlook) and the ability to navigate multiple screens 


• Strong written and verbal communication skills 


• Ability to function in a high volume, fast paced environment 

Additional Preferred Assets:

• BSN 


• Knowledge of Milliman (MCG) and/or InterQual criteria 


• 
  

  Medicaid and Medicare/CMS criteria



• Previous managed care experience (Prior Authorization, Utilization Management)


• Understanding of DME Prior Auth


• 
  

  ICD 9/ICD 10 coding



• 
  

  Diagnostic/procedure (CPT coding)



• 
  

  Critical Care Experience

  
  

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.




UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.

Job Keywords:   RN, Registered Nurse, Prior Authorizations, Concurrent Review, Managed Care, Utilization, Utilization Management, Prior Auths, Telecommute, Nashville, Memphis, Knoxville, Chattanooga, Tennessee, TN