Prior Authorization Review Nurse

Are you ready for your next challenge? Discover it here at UnitedHealthcare and help us reinvent the health system. This can be your opportunity to take on a role that helps us offer a higher level of care than you’ll find anywhere else. Put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. You will discuss cases with treating physicians and other healthcare professionals to ensure our members receive the proper health services. You will be required to maintain communication with acute long-term care, acute rehabilitation, or skilled nursing facilities in order to help patients through their care plan. This is an exciting opportunity at a truly inspired organization. Join us. This can be the start of your life’s best work.(sm)  

What makes your nursing career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You will work within an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you’ll open doors for yourself that simply do not exist in any other organization, anywhere.

This role will be performing outpatient clinical coverage review services, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information.  

This employee can choose hours within the time frame of 8:00am and 6:00pm in their time zone.  Rotating Saturdays are required as well (approximately every 6 to 12 weeks).  You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.  

Primary Responsibilities:

• Function as a member of a self-directed team to meet specific individual and team performance metrics
• Ability to communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations
• Telephonic discussion with health care providers and / or members to explain benefit coverage determinations and to obtain additional clinical information
• Acts as a resource for others with less experience
• Work independently and collaborating with Medical Directors and non-clinical partners
• Adapt to a highly changing environment and a heavy case load

Required Qualifications:

• A current unrestricted Compact State RN license in the state of residency
• 3+ years as a Registered Nurse (RN)
• 3+ years of RN clinical experience in a hospital inpatient/acute care setting
• Demonstrate a proficiency in computer skills – Windows, Instant Messaging, Microsoft Suite including Word, Excel and Outlook
• Exemplary clinical documentation skills; critical thinking skills
• Excellent communication skills both verbal and written
• Must dedicated, distraction-free, space for home office
• Access to install secure high-speed internet (minimum speed 1.5 download mps & 1 upload mps) via cable / DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement)
• If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders

Preferred Qualifications:

• NLC (Nurse License Compact) RN license or have an RN license in an eNLC state and can apply
• Bachelor’s Degree
• Background involving utilization review for an insurance company or experience in case management
• Familiarity with Milliman Care Guidelines or Interqual
• The ability to work seamlessly and independently in multiple computer platforms
• The ability to be flexible and willing to adapt to an ever-changing environment

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)

Colorado Residents Only: The hourly range for Colorado residents is $25.63 to $45.72. Pay is based on several factors including but not limited to education, work experience, certifications, etc. As of the date of this posting, In addition to your salary,  UHG offers the following benefits for this position, subject to applicable eligibility requirements: Health, dental, and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term disability insurance, and long-term disability insurance; business travel accident insurance; Employee Assistance Program; PTO; and employee-paid critical illness and accident insurance.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Keywords: Preservice Review, Nurse, RN, Prior Authorization, Preservice, Utilization Review, remote, Telecommute, Telecommuter, acute care, hospital inpatient, med surg, medical surgical, ER, emergency room, TX, TN, Medicare, Medicaid, Interqual, MCG, Milliman, medical necessity