Radiation Oncology Preservice Review Nurse RN

About the position 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. We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. 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. Determines medical appropriateness of outpatient services following evaluation of medical guidelines and benefit determination. Ready for a new path? today! This position is work at home. Work schedule is full time and offers some flexibility with a combination of day and consumer hours. Some evening, holidays and weekend hours will be required. Core schedule is normal daytime business hours. Three evenings per month will be required to work until 7pm, one weekend day will be required approximately every 3 months, ability to work 5/8's or 4/10's after training based on business need.

Responsibilities

• 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)
• 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)

Requirements

• 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, to include 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 set up
• Ability to work schedule listed

Nice-to-haves

• 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

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