Nurse Reviewer LPN

By | October 12, 2022

Job Responsibilities : Nurse Reviewer LPN

Salary : $32.26 per hour

Company : Optum

Location : Remote US

Educational requirements : High School

Combine two of the fastest-growing fields on the planet with a culture of performance collaboration and opportunity and this is what you get. Leading edge technology in an industry that’s improving the lives of millions. Here innovation isn’t about another gadget it’s about making health care data available wherever and whenever people need it safely and reliably. There’s no room for error. Join us and start doing your life’s best work.(sm)

Responsible for telephonically managing the medication regimen for a claimant following an injury. The Nurse Reviewer LPN monitors medical treatment and acts as a liaison between the account and provider to monitor and aggressively manage the medication regimen in accordance with the ODG formulary and FDA guidelines for cost effective outcomes.

Work Schedule: Ability to work a consecutive 8 hour shift between the hours of 11:30am-8pm EST Monday through Friday with flexibility to work weekends and or holidays as needed.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

  • Provides clinical review service inclusive of but not limited to Rx Prior Auth medication reviews for eligibility and medical necessity of the Rx Nurse Progress Monitoring in follow up to a Peer Review to facilitate changes to a medication Letter of Medical Necessity outreach both written and oral to secure physician substantiation for designate drug classes as defined by the account Opioid Case Management early intervention for opioid monitoring weaning and cessation and Prior Authorization Request (PAR/PARF) and/or Request for Authorization (RFA) reviews for pre-certification of medications submitted in compliance with State Formularies
  • Reviews and adjudicates medications smart routed to the Clinician. Medication reviews encompass evaluation of relatedness to injury and medical necessity to the injury in correlation to compliance with formulary and evidence based guidelines to include ACOEM ODG and WC State mandated medical treatment guidelines as well as client’s benefit plan
  • Utilizes Vital Point to evaluate Rx refill patterns and any changes to medication as well as contraindications of use with other medications for any safety risks
  • Applies step therapy methodology to insure compliance with medical treatment guidelines
  • Recognizes risk management opportunities to work with the physician for alternative Rx with same therapeutic value but more cost effective; evaluates Rx for brand to generic conversions; and assesses potential of duplication of medications prescribed accessing internal pharmacist staff for expert opinion to communicate with the physician on basis of recommendations
  • Actively identifies prepares and participates in conversations with prescribers for compliance to the guidelines and or conversion of medications to formulary and or step therapy. On occasion there may also be times where outreach is needed to the patient employer or adjuster
  • Provides written analysis of the rationale of the determination basis rendered by the Clinician to support the approval and or block of the medication
  • Processes determinations across all services in accordance with Service Level Expectations for each client and in conjunction with State regulations
  • Reviews Rx card eligibility in accordance with plan eligibility per client and coordinates with client and Optum Pharmacy support to validate card services
  • Prepares all prescriber/attorney/claimant letters and sends to Case Manager Assistant (CMA) for formatting and mailing
  • Provides Updates to the adjuster on as requested basis in a timely manner (same day) via email and/or phone as determined appropriate by level of urgency
  • Recordkeeping and hourly billing is critical task in this position; this requires inputting notes and time entry on “all” tasks performed/received utilizing the proprietary claim system RMS for each file worked; in addition posts all created and received documents in the RMS Admin tab for each file’s historical reference. Additionally utilizing recordkeeping in other proprietary claim systems as defined by the service/account handling procedures.
  • Flexibility to work in multiple system applications/platforms simultaneously as well as participate in cross training opportunities as identified to flex ability to assist within the Unit to the operational need as needed. Ensures confidentiality and maintains accurate record keeping
  • Attends in services and continuing education seminars as appropriate to renew licensure and meet Company requirement of 12 CEUs per year
  • Utilizes effective oral written and organization skills and demonstrates the ability to prioritize case activities
  • Responsible for providing any changes to licensure immediately upon occurrence and notice from the State. (Renewal Suspension Termination etc.) Maintains keeping all license status updates in the Corporate PAL platform on a timely basis
  • Holds to the philosophy and standards of quality as outlined by Optum a division of UnitedHealth
  • Performs other clinical pharmacy services duties as required by Manager and or Operational demand

What are the reasons to consider working for UnitedHealth Group? Put it all together – competitive base pay a full and comprehensive benefit program performance rewards and a management team who demonstrates their commitment to your success. Some of our offerings include:

  • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
  • Medical Plan options along with participation in a Health Spending Account or a Health Saving account
  • Dental Vision Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
  • 401(k) Savings Plan Employee Stock Purchase Plan
  • Education Reimbursement
  • Employee Discounts
  • Employee Assistance Program
  • Employee Referral Bonus Program
  • Voluntary Benefits (pet insurance legal insurance LTC Insurance etc.)
  • More information can be downloaded at:

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • High School Diploma/GED (or higher)
  • Valid RN or LPN license (LPN’s may be considered if preferred qualifications are met)
  • 3+ years of related nursing case management experience
  • 1+ year of clinical background with exposure to prescription medications
  • 1+ year of experience working with electronic medical records and/or electronic claims systems
  • 1+ year of telecommuting experience
  • Intermediate level of proficiency with Microsoft Word and Outlook
  • Intermediate level of proficiency in technology with the ability work in multiple claim platforms simultaneously
  • Ability to work a consecutive 8 hour shift between the hours of 11:30am-8pm EST Monday through Friday with flexibility to work weekends and or holidays as needed
  • Full COVID-19 vaccination is an essential requirement of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal state and local regulations as well as all client requirements and will obtain necessary proof of vaccination and boosters when applicable prior to employment to ensure compliance

Preferred Qualifications:

  • Bachelor’s Degree in Nursing
  • Clinical background with Prescription (Rx) management specific to opioids
  • Proficiency with Microsoft Excel
  • CCM

To protect the health and safety of our workforce patients and communities we serve UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition some roles and locations require full COVID-19 vaccination including boosters as an essential job function. UnitedHealth Group adheres to all federal state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers with Optum . Here’s the idea. We built an entire organization around one giant objective; make health care 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)

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Colorado Connecticut or Nevada Residents Only : The salary range for Colorado residents is $18.17 to $32.26. The salary range for Connecticut / Nevada residents is $20.00 to $35.53. Pay is based on several factors including but not limited to education work experience certifications etc. In addition to your salary UnitedHealth Group offers benefits such as a comprehensive benefits package incentive and recognition programs equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group you’ll find a far-reaching choice of benefits and incentives.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action 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.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.

#RPO #Green

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