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Clinical Review Coordinator - National Remote

Company: UnitedHealth Group
Location: Storrs Mansfield
Posted on: May 29, 2023

Job Description:

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

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

This position is full-time 40 hours/week. Thursday - Sunday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 1:00pm - 12:00am. It may be necessary, given the business need, to work occasional overtime.

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

Primary Responsibilities:

  • Ensure timely processing of all denial- related and member-oriented written communications from naviHealth. Ensure that all denial information is processed according to protocol and that all documentation is timely and meets all Federal and State requirements.
  • Ensure second-level reviews have been performed and documented and may confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICC's), Skilled Inpatient Care Coordinators (SICC's), Pre-service Coordinators (PSC's) and facility personnel in determining denial information is processed timely and appropriately utilizing naviHealth proprietary technology.
  • Serve as a liaison with regards to communicating to internal and external customers, including health plans, providers, members, quality organizations and other naviHealth colleagues.
  • Document and communicate appeal and denial information via fax, email, or through established portal access, including d appeal and denial letters, NOMNC letters, AOR forms, clinical information.
  • Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their team.
  • Serve as a liaison for requests for information from QIO or health plan staff.
  • Own assigned appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management.
  • Complete appeal and denial processes in accordance with CMS and naviHealth guidelines and compliance policies.
  • Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability (including proper grammar, spelling, punctuation, etc.), as well as ability to follow grade-level requirements. (Including, but not limited to DENC letter, IDN letter, Exhaustion of Benefits letter, Administrative Denial letter, Provider Denial letter).
  • Review NOMNC for validity before processing appeal requests.
  • Send review to Medical Director for rescinding NOMNC when necessary, following naviHealth processes.
  • Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed.
  • Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed.
  • Follow all established facility policies and procedures.
  • Assist with completing pre-service authorization requests to assist the pre-service team as needed.
  • Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs.
  • Perform other duties and responsibilities as required, assigned, or requested.
    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)
    • Active, unrestricted registered clinical license required - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist
    • 3+ years of clinical experience
    • Understanding of market variability related to the denial process, specific contractual obligations, and CMS regulations
    • Ability to work full-time. Thursday - Sunday, 1:00pm - 12:00am
      Preferred Qualifications:
      • Experience with appeals and/or denials processing
      • Managed care experience
      • ICD-10, and InterQual experience a plus and CMS knowledge
      • Current knowledge of multiple naviHealth contracts
      • For RNs, Compact Nursing License, and multiple state licensures
      • For Physical Therapy, Compact Licensure, and multiple state licensures
        Telecommuting Requirements:
        • Required to have a dedicated work area established that is separated from other living areas and provides information privacy
        • Ability to keep all company sensitive documents secure (if applicable)
        • Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
          Soft Skills:
          • Strong technical/computer skills
          • Excellent documentation skills
          • Exceptional verbal and written interpersonal and communication skills
            Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere.

            As a team member of our naviHealth product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home.

            We're connecting care to create a seamless health journey for patients across care settings. Join our team, it's your chance to improve the lives of millions while doing your life's best work. sm

            California, Colorado, Connecticut, Nevada, Washington, or New York, Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / Washington / New York / Rhode Island residents is $32.60 - $63.99. 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

            At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

            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.



Keywords: UnitedHealth Group, New England , Clinical Review Coordinator - National Remote, Healthcare , Storrs Mansfield, Northeast

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