This position is for a Clinical Nurse working in the Prior Authorization and Appeals unit of OptumRx, a UnitedHealth Group company. This is a call center based business segment and strict work guidelines are employed. The nurse’s primary role is reviewing Prior Authorization and Appeals cases and rendering coverage determinations based on clinical criteria and plan design in a fast paced and dynamic environment.
· Work is computer based and includes receiving phone calls from prior authorization pharmacy technicians and/or providers for clinical information
· Consult physicians/providers with questions, interpret clinical guideline criteria, and render/review coverage determination for prior authorization cases
· Consult with pharmacy technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when requested.
· Gather complex clinical information, coverage policy and criteria information and work within regulatory guidelines to make coverage determinations
· Organize workload, set priorities, complete assignments in a timely manner and utilize resources appropriately while complying with department program standards
· Perform all duties and functions in compliance with state and federal pharmacy laws and regulations
· Conform with and supports department quality assurance and improvement guidelines
· Dedication to build rapport with coworkers, internal customers, and other departments by demonstrating a strong customer service orientation and a continuous positive image of OptumRx.
· Demonstrate ability to maintain productive working relationships with team members, other internal and external customers, and management team.
- Active USRN License
- Experience working within the Healthcare Industry
- Working knowledge of Medical Terminology to communicate with members and providers
- Ability to create, edit, save and send documents utilizing Microsoft Word and Excel
- Ability to navigate a PC to open applications, send emails, and conduct data entry
- Hospital experience in Critical Care areas
- Professional experience in a clerical or administrative support related role
- Experience working with Healthcare Insurance
- Experience working with ICD-9 and CPT codes
- Experience working with Medicare and/or Medicaid Services
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do
your life's best work.(sm)
Diversity creates a healthier atmosphere: Optum is an Equal Employment Opportunity 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.
Optum is a drug-free workplace. © 2020 Optum Global Solutions (Philippines) Inc. All rights reserved.
Job Keywords: USRN, US Registered Nurse, US Nurse, United States Nurse, United States Registered Nurse, Registered Nurse, RN, Quezon City, NCR, National Capital Region