Preservice Review Nurse RN

Optum Health Optimization

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.

Positions in this role are responsible for Women's Health/ Gender Dysphoria/ Genetics clinical reviews and require a current, unrestricted RN nursing license in the applicable state. Individual is responsible for performing pre-service clinical coverage review of outpatient Women's Health/ Gender Dysphoria/ Genetics services which require notification or requested pre-determination, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria.

Primary Responsibilities:

• Perform clinical reviews, which require decision making related to interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
• Ability to make appropriate clinical decisions within a business environment
• Serve as a member of a team with specific individual and team performance metrics
• Communicate in writing and verbally, all forms of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations
• Work independently and collaboratively with Medical Directors and other business partners
• Flexibility to adapt to changing environment and varied case volume
• Other duties as assigned by leadership

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Active, unrestricted Registered Nurse license through the State of Florida
• 3+ years of RN patient care experience
• Proficiency working with Microsoft Office Products including Microsoft Outlook (ability to create, edit, save, and send emails), Microsoft Word (ability to create, edit, save, and send documents), and Microsoft Excel (ability to create, edit, save, and send spreadsheets)
• Reside in Florida

Preferred Qualifications:

• Bachelor's degree
• Background involving utilization review or experience in case management, or previous experience with clinical claim review
• Familiarity with utilizing clinical guidelines (i.e.; Medicare, state, MCG or InterQual)
• Proven solid clinical judgement while applying medical necessity based on approved clinical resources

If the hired individual resides in Florida (office based or telecommuting) this position requires the AHCA Level II background check (fingerprinting) by the State of Florida for all clinicians that have direct face to face contact with members OR employees who will have access to confidential patient data and will require renewal every five years.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable.