Preservice Review RN (Remote in HI)

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

• 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

• 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 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)

• Demonstrate understanding of business implications of clinical decisions to drive high quality of care
• Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS, NCQA/URAC accreditation)
• Ask critical questions to ensure member- and customer-centric approach to work
• Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
• Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes
• Use appropriate business metrics to optimize decisions and clinical outcomes
• Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up)

• Meet/exceed established productivity goals
• Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations -Manage/prioritize workload and adjust priorities to meet quality and productivity goals

• Ask critical questions to ensure member/customer centric approach to work
• Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as needed
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
• Identify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performance
• Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, healthcare reform, URAC/NCQA/ERISA/state accreditation)

• Valid RN license in Hawaii
• Residence in Hawaii
• 3+ years of RN experience in an acute setting
• Advanced computer proficiency (Microsoft Word, Outlook, and Internet)
• Saturday availability

• 3+ years of experience as an RN in utilization management

UnitedHealth Group