Radiation Oncology Preservice Review Nurse RN

About the position

The Telephonic Oncology Preservice Review Nurse at UnitedHealth Group is responsible for performing pre-service clinical coverage reviews of outpatient services that require notification. This role involves evaluating medical appropriateness based on established guidelines and benefit plans, ensuring compliance with federal and state requirements, and conducting non-clinical research to support decision-making. The position offers the flexibility to work remotely while requiring some evening, holiday, and weekend hours.

Responsibilities
? Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial)
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? Validate that cases/requests for services require additional research
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? Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources)
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? Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
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? Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
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? Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
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? Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
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? 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)
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? Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
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? Apply understanding of medical terminology and disease processes to interpret medical/clinical records
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? Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
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? Review care coordinator assessments and clinical notes, as appropriate
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? Identify relevant information needed to make medical or clinical determinations
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? 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
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? Ability to obtain licensure in other states as needed
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? 2+ years of Radiation Oncology experience as a Nurse
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? Computer proficiency, to include solid data entry skills and the ability to navigate a Windows environment
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? Access to high speed internet from home (Broadband cable, Fiber or DSL)
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? Dedicated workspace for home office set up
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? Ability to work schedule listed

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

Benefits
? Comprehensive benefits package
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? Incentive and recognition programs
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? Equity stock purchase
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? 401k contribution

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