As a Telephonic Oncology Preservice Review Nurse you will be performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of outpatient services following evaluation of medical guidelines and benefit determination.
This position is work at home. Work schedule is full time and offers some flexibility with a combination of day and consumer hours. Some evening, holidays and weekend hours will be required. Core schedule is normal daytime business hours. Three evenings per month will be required to work until 7pm, one weekend day will be required approximately every 3 months, ability to work 5/8's or 4/10's after training based on business need.
Primary Responsibilities
- Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial)
- 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)
- Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
- Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
- Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs)
- Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
- Apply understanding of medical terminology and disease processes to interpret medical/clinical records
- Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
- Review care coordinator assessments and clinical notes, as appropriate
- Identify relevant information needed to make medical or clinical determinations
- Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical
- This position will require active and unrestricted Nursing licensure in multiple US States. Selected candidate must be willing and able to obtain and maintain multiple state licensure (Application fees and filing costs paid for by UHG)
Required Qualifications
- Current, unrestricted RN license in your state of residence
- Ability to obtain licensure in other states as needed
- 2+ years of Radiation Oncology experience as a Nurse
- Computer proficiency, to include solid data entry skills and the ability to navigate a Windows environment
- Access to high speed internet from home (Broadband cable, Fiber or DSL)
- Dedicated workspace for home office set up
- Ability to work schedule listed
Preferred Qualifications
- OCN Certification
- Chemo/Bio Certification
- Certified Case Manager (CCM)
- 7+ years of Radiation Oncology experience
- ICD Coding experience or solid knowledge of codes
- NCCN experience
- Background in preservice review/utilization review/utilization management
The hourly pay for this role will range from $29.00 - $52.00 per hour based on full-time employment.