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Hours Full-time, Part-time
Location Las Vegas, NV
Las Vegas, Nevada

About this job


Are you ready for your next challenge? Discover it here at UnitedHealthcare and help us reinvent the health system. This can be your opportunity to take on a role that helps us offer a higher level of care than you'll find anywhere else. Put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. You will discuss cases with treating physicians and other healthcare professionals to ensure our members receive the proper health services. You will be required to maintain communication with acute long term care, acute rehabilitation, or skilled nursing facilities in order to help patients through their care plan. This is an exciting opportunity at a truly inspired organization. Join us. This can be the start of your life's best work.(sm)
 
The Preservice Review RN is responsible for reviewing requests received from providers, using approved protocols and criteria. (Milliman Care Guidelines or Healthcare Operations Protocols). The RN is expected to approve those requests that meet medical necessity, along with benefit level, and the contractual status of the provider / facility as appropriate for all fully-funded lines of business. This position is also a resource to new staff and may precept as well.
 
***This is an office based role located at 2716 N Tenaya in Las Vegas, NV***
Primary Responsibilities: 


Evaluate and assess each request verifying eligibility and specific product
Determine benefit level based on site of service
Utilize written criteria to approve, pend or send the case to the medical director for review
Pend cases by documenting in the claim's payment system, contacting the provider for the necessary information via fax and / or phone and sending a letter to the member to alert them of the pending decision
Maintain 100% accuracy of clinical review case notes in Facets
Maintain productivity standards and maintain compliance with all regulatory agencies including NCQA, DOL, DOI for each state, Medicaid, CMS, and OPM
Maintain 100% accuracy in summarizing cases for the Medical Director to review using appropriate protocols based members clinical and benefit information
Maintain compliance with turnaround times based on the member's product, the type of request and the specific regulatory agency
Be knowledgeable of and comply with the Nurse Practice Act for each state that licensure is required to perform SHL business
Precepts / act as resource for new staff

Requirements


Required Qualifications: 


Nursing degree (Associates level or higher)
A current, unrestricted RN license in state of hire
2+ years of nursing experience (varied in at least 2 of the following: M/S, Critical Care, ER, surgical)
Detail oriented, excellent organizational skills
Ability to work well under pressure with sound decision making ability
Excellent written and oral communication skills
Should be self-sufficient and assertive
Computer proficiency
Preferred Qualifications:


2+ years Utilization Management experience in managed care, acute, or rehab setting desired
Knowledge of utilization review process and prior authorization process in a managed health care industry
Knowledge of ICD9 / CPT coding, and Milliman Care Guidelines
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work. (sm)
 
 
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.  
 
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
Job Keywords: prior authorizations, utilization management, RN, registered nurse, Las Vegas, NV, Nevada, nursing, UM, UR