RN Prior Authorization Nurse - Remote

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Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.

As an RN, Unitarization Managment, you will be responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making as it relates to the application of criteria and defined levels of hierarchy and composition of compliant denial notices.

If you are licensed in California, you will have the flexibility to work remotely as you take on some tough challenges.

Primary Responsibilities:

• Consistently exhibit behavior and communication skills demonstrating Optum's commitment to superior customer service, including quality, care, and concern with every internal and external customer
• Perform all functions of a UM nurse reviewer
• Compose denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards
• Construct denial notices to ensure the intended recipients understand the rationale for the denial of service and are specific to the member's condition and request
• Ensure the denial reason is in the appropriate grade level and is easily understandable
• Ensure the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria, or protocols based on the type of denial
• Select the correct hierarchy level and apply it correctly based on the available medical information
• Provide relevant clinical information to the request and the criteria used for decision-making
• Ensure that there is evidence that the UM nurse reviewer documented communications with the requesting provider to validate the presence or absence of clinical information related to the criteria applied
• Evaluate out-of-network and tertiary denials for accessibility within the network
• Perform a quality assurance audit on each denial before finalization to ensure all elements comply with established guidelines
• Consult with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination
• Escalate non-compliance cases to UM compliance and consistently report on denial activities
• Collaborate with UM compliance for continued quality improvement efforts for adverse determinations
• Identify gaps in training or process impacting the overall compliance of adverse determinations and communicate an effective performance improvement solution in writing
• Meets or exceeds productivity targets
• Uses, protects, and discloses Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Performs additional duties as assigned