[Hiring] Telephonic Oncology Preservice Review Nurse @UnitedHealth Group

Role Description

As a Telephonic Oncology 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. You will:

• 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)
• 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
• 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)

This position is work at home with a full-time schedule that offers some flexibility, including:

• Normal daytime business hours
• Three evenings per month until 7 PM
• One weekend day approximately every 3 months
• Ability to work 5/8's or 4/10's after training based on business need

Qualifications

• Current, unrestricted RN license in your state of residence
• Ability to obtain licensure in other states as needed
• 2+ years of Radiation Oncology experience as a Nurse
• Computer proficiency, including solid data entry skills and the ability to navigate a Windows environment
• Access to high-speed internet from home (Broadband cable, Fiber or DSL)
• Dedicated workspace for home office setup
• Ability to work schedule listed

Requirements

• OCN Certification
• Chemo/Bio Certification
• Certified Case Manager (CCM)
• 7+ years of Radiation Oncology experience
• ICD Coding experience or solid knowledge of codes
• NCCN experience
• Background in preservice review/utilization review/utilization management

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)

Application Deadline

This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.