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Preservice Review Nurse RN - Las Vegas, NV

UnitedHealth Group

Las Vegas, NV
Job Code:
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Job Details

Preservice Review Nurse RN - Las Vegas, NV(Job Number:717488)

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)
The Preservice Review RN is responsible for reviewing requests received from providers, using approved protocols and criteria. (Milliman Care Guidelines or Healthcare Operations Protocols). The RN is expected to approve those requests that meet medical necessity, along with benefit level, and the contractual status of the provider / facility as appropriate for all fully - funded lines of business. This position is also a resource to new staff and may precept as well.

***This is an office based role located at 2716 N Tenaya in Las Vegas, NV***

Primary Responsibilities: 
  • Evaluate and assess each request verifying eligibility and specific product
  • Determine benefit level based on site of service
  • Utilize written criteria to approve, pend or send the case to the medical director for review
  • Pend cases by documenting in the claim's payment system, contacting the provider for the necessary information via fax and / or phone and sending a letter to the member to alert them of the pending decision
  • Maintain 100% accuracy of clinical review case notes in Facets
  • Maintain productivity standards and maintain compliance with all regulatory agencies including NCQA, DOL, DOI for each state, Medicaid, CMS, and OPM
  • Maintain 100% accuracy in summarizing cases for the Medical Director to review using appropriate protocols based members clinical and benefit information
  • Maintain compliance with turnaround times based on the member's product, the type of request and the specific regulatory agency
  • Be knowledgeable of and comply with the Nurse Practice Act for each state that licensure is required to perform SHL business
  • Precepts / act as resource for new staff

Job Clin Coverage Rvw/Prior Author
Primary Location US-NV-Las Vegas
Other Location 
Organization E&I Nevada-Utah-Idaho
Schedule Full-time
Number of Openings 1
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UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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