WHO WE AREOptum is a part of the UnitedHealth Group, a Fortune 5 company, serving 125 million individual consumers.We are a diverse company with over 189,000 employees worldwide and over 14,000 employees in the Philippines.We are a leader in nearly every aspect of today?s health care landscape.We leverage on having the largest single proprietary network of physicians, hospitals, health facilities, and caregivers in the United States.At Optum, we believe that what makes you special can inspire your life?s best work.Welcome to one of the toughest and most fulfilling ways to help people, including you.We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement.Join us and start doing your life?s best work.SM. JOB QUALIFICATIONSValid and unrestricted USRN license and PHRN License preferredHolder of Non-Mainland USRN license are welcome to applyPreferably with 1 year nursing experience or BPO USRN experienceClinical competence in understanding hospital care and care coordinationWHAT WE OFFERMarket Total Rewards PackageTemporary Work From Home, Computer/Laptop Provided by the CompanyUp to 100K Sign On Bonus! Terms and Conditions ApplyRetirement PlanMedical Plan (HMO) from Day 1 of employmentDental, Medical, and Optical ReimbursementsLife and Disability InsurancePaid Time-Off BenefitsSick Leave ConversionTuition Fee ReimbursementEmployee Assistance Program (EAP)Annual Performance Based Merit IncreasesEmployee RecognitionTraining and Staff DevelopmentEmployee Referral ProgramEmployee Volunteerism OpportunityAll Mandatory Statutory BenefitsROLE AND RESPONSIBILITIESFunction is responsible for 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 inpatient and outpatient services following evaluation of medical guidelines and benefit determination.Conduct Non-Clinical Research to Support Determinations.Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan)Review Existing Clinical Documentation.Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)Make Final Determinations Based on Clinical and Departmental Guidelines.Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation)Achieve and Maintain Established Productivity and Quality Goals.Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations.Your role is critical in allowing our members, families, facilities and health professionals to have greater confidence in the exceptional care we provide.And for you, an everyday opportunity to do your life?s best work.SM.
