Preservice Review Nurse RN - Remote Hawaii Join to apply for the Preservice Review Nurse RN - Remote Hawaii role at Optum . 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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. Overview General Job Profile Generally work is self-directed and not prescribed Works with less structured, more complex issues Serves as a resource to others Primary Responsibilities 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 Functional Competencies CPS – Conduct Non-Clinical Research to Support Determinations Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) and 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) CPS – Review Existing Clinical Documentation Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) and identify missing information; request additional documentation as needed Review and validate diagnostic/procedure/service codes for relevance and accuracy as applicable Identify and validate usage of non-standard codes as necessary Apply understanding of medical terminology and disease processes to interpret records Make determinations per relevant protocols (e.g., approval, denial, further research) Review care coordinator assessments and clinical notes as appropriate CPS – Conduct Clinical Research to Support Determinations Identify relevant information needed to make medical or clinical determinations Identify and utilize medically-accepted resources and systems to conduct clinical research Obtain information from patients, providers and/or care coordinators as needed to verify services rendered Apply knowledge of state/federal mandates, benefit language, and policies to support determinations Collaborate with internal stakeholders to drive the clinical coverage review process CPS – Make Final Determinations Based on Guidelines Demonstrate understanding of business implications of clinical decisions Adhere to applicable legal/regulatory requirements (e.g., HIPAA, CMS, NCQA/URAC) Ask critical questions to ensure member- and customer-centric approach Identify options to mitigate issues related to quality, safety or risk and escalate as needed Use evidence-based guidelines to make clinical decisions and improve outcomes Identify innovative approaches to nursing to achieve quality outcomes Use business metrics to optimize decisions and outcomes CPS – Achieve and Maintain Productivity and Quality Goals Meet/exceed productivity goals Adhere to quality audit standards in reviews and documentation CPS – Drive Effective Clinical Decisions Within a Business Environment Ask critical questions for a member/customer-centric approach Identify options to mitigate quality/safety/affordability issues and escalate as needed Use guidelines to make decisions and improve outcomes Innovate in nursing practice to enhance outcomes and financial performance Operate within legal/regulatory requirements Compensation note: Pay is based on factors including local labor markets, education, and experience. Benefits include a comprehensive package, incentive programs, equity and 401k contributions. The hourly pay range is from $28.27 to $50.48 for full-time use. This is subject to applicable laws. Required Qualifications Valid RN license in Hawaii 3+ years of RN experience in an acute setting Advanced computer proficiency (Microsoft Word, Outlook, Internet) Saturday availability Residence in Hawaii Preferred Qualifications 3+ years of RN experience in utilization management Remote employees must adhere to UnitedHealth Group's Telecommuter Policy Application Deadline: This posting will be available for a minimum of 2 business days or until a sufficient candidate pool is collected. The posting may end early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We are an Equal Employment Opportunity/Affirmative Action employer. We value diversity and are committed to building an inclusive environment. UnitedHealth Group is a drug-free workplace; candidates must pass a drug test before beginning employment. Seniority level Entry level Employment type Full-time Job function Health Care Provider Industries Nursing Homes and Residential Care Facilities Referrals increase your chances of interviewing at Optum by 2x. Get notified about new Registered Nurse jobs in Honolulu, HI. #J-18808-Ljbffr Optum