US Registered Nurse - Preservice Review Nurse

Description - External

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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)

Location: This role is available in the following locations Alabang, Davao, Cebu, Taguig, Makati and Quezon City

Primary Responsibilities:

• Checks the benefit plan coverage of the member and review their condition against United Health Care's Medical Policy if the procedure they're requesting will be approved or not.

• Perform clinical coverage review of services... which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information

• Complete approval coverage determinations according to applicable medical policy and guidelines

• Prepares cases for physician review

• 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 members to explain benefit coverage and medical necessity determinations and to obtain additional clinical information

• Acts as a resource for others with less experience

Qualifications - External

Required Qualifications:

• Undergraduate degree or equivalent experience.

• Must be a registered nurse with an US mainland active license.

• With at least 1 year of Clinical and bedside experience or any UM/ UR related experience

• With computer skills.

• With or Without BPO experience.

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges
Manila Metro Manila Philippines

Salary Criteria