Registered Nurse RN Prior Authorization Nurse Healthcare Compact Lics

About the position The Registered Nurse (RN) Prior Authorization Nurse at Optum is responsible for reviewing proposed hospitalization, home care, and treatment plans to ensure medical necessity and efficiency according to CMS coverage guidelines. This role involves determining the appropriateness of inpatient and outpatient services, utilizing decision-making and critical-thinking skills, and working under the supervision of an RN or MD. The position offers the flexibility to work remotely for those with a Compact license. Responsibilities • Perform utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines. , • Determine medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidence-based guidelines/criteria. , • Utilize decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. , • Answer Utilization Management directed telephone calls, managing them in a professional and competent manner. , • Refer cases to a review physician when treatment requests do not meet necessity per guidelines or when guidelines are not available. , • Review, document, and communicate all utilization review activities and outcomes, including all calls made and received regarding case communication. , • Send appropriate system-generated letters to providers and members. , • Provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses. , • Identify and refer all potential quality issues to the Clinical Quality Management Department and suspected fraud and abuse cases to the Compliance Department. , • Conduct rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies. , • Document rate negotiation accurately for proper claims adjudication. , • Identify and refer potential cases to Disease Management and Case Management. , • Perform all other related duties as assigned. Requirements • Current, unrestricted Texas RN license or compact license. , • 2+ years of experience in managed care OR 5+ years of nursing experience. , • Proficient in PC Software computer skills. Nice-to-haves • Authorization experience. , • Telephonic and/or telecommute experience. , • Utilization Review/Management experience. , • ICD-10, CPT coding knowledge/experience. , • InterQual or Milliman knowledge/experience. , • Proven excellent communication skills both verbal and written. , • Proven solid problem-solving and analytical skills. , • Proven ability to interact productively with individuals and multidisciplinary teams with minimal guidance. Benefits • 401(k) matching , • comprehensive benefits package , • incentive and recognition programs , • equity stock purchase Apply Job!