US Registered Nurse
Optum, Inc.
Taguig City, National Capital Region
5d ago

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)

Primary Responsibilities :

  • 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 the business
  • Demonstrate ability to maintain productive working relationships with team members, other internal and external customers, and management team
  • Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and / or re-assignment to different work locations, change in teams and / or work shifts, policies in regards to flexibility of work benefits and / or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment).
  • The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

    Required Qualifications :

  • 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
  • Preferred Qualifications :

  • 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
  • Preferably with working internet connection of at least 15 mbps in case of working from home. The following options are also available :
  • Corporate internet subsidy for those within available and valid serviceable locations, subject to Company Policy

    Onsite work for those who are amenable to drive or commute to our office locations

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