Clinical Review Coordinator - Hybrid - 2208886
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 us to start Caring. Connecting. Growing together.
At naviHealth, our mission is to work with extraordinarily talented people who are committed to making a positive and powerful impact on society by transforming health care. naviHealth is the result of almost two decades of dedicated visionary leaders and innovative organizations challenging the status quo for care transition solutions. We do health care differently and we are changing health care one patient at a time. Moreover, have a genuine passion and energy to grow within an aggressive and fun environment, using the latest technologies in alignment with the company’s technical vision and strategy.
This position is full-time. Employees are required to work Monday-Friday, 8:00am-5:00 pm Eastern Standard Time (EST) including the flexibility and willingness to work an early or late shift and/or longer than normal hours to accommodate peaks in volume of work based on business need.
We offer weeks of paid training. The hours of the training will be based on schedule or will be discussed on your first day of employment.
If you live within 30 minutes of Burlington, MA you will have the flexibility to work remotely*, as well as work in the office as you take on some tough challenges.
- Responsible for reviewing and determining medical appropriateness of pre-authorization requests following evaluation of medical guidelines
- Coordinates the transition of patients from the community or acute setting to the next appropriate level of care
- Complete process as it relates to pre-service authorizations
- Participate in the clinical phone queue to ensure customer’s Service Level Agreements are met
- Provide written and verbal coordination of care communication with a full team which may consist of, but is not limited to, Medical Directors, Skilled Inpatient Care Coordinators, and Clinical and/or Operations leadership
- Positions are responsible for providing appropriately focused Medical Management Clinical Review of Medical Policy, Health Plan Policy, Member Benefits, and Standards of Policy/Work Instructions
- Uses technical knowledge and related review protocols in the review of clinical information and documents as they relate to company medical policy and benefit document language
- Educate facilities on the pre-service authorization process
- Perform other duties and responsibilities as required, assigned, or requested within your scope of licensure
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.
- Associate’s Degree (or higher) WITH equivalent experience for RNs OR Bachelor’s Degree (or higher) in Occupational Therapists OR Physical Therapists
- Active, unrestricted registered clinical license- Registered Nurse, Physical Therapist, Occupational Therapist
- 3+ years of clinical experience
- Ability to work any shift between the hours of 8:00am – 5:00pm CST (Central Standard Time) from Monday – Friday including the flexibility and willingness to work occasional overtime (an early or late shift and / or longer than normal hours to accommodate peaks in volume of work) and weekends based on business need
- Bachelor’s Degree (if the candidate is an RN)
- 2+ years of Case Management/Utilization Management experience
- Experience in acute care, acute inpatient rehabilitation hospital, or skilled nursing facility environment
- Managed Care experience
- Experience with performing clinical audits to improve quality standards or performance
- Experience in working with geriatric population
- Knowledge and experience working with ICD-10 codes and InterQual
- Knowledge and experience with CMS guidelines
- Ability to keep all company sensitive documents secure (if applicable)
- Required to have a dedicated work area established that is separated from other living areas and provides information privacy
- Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
- Ability to review patients clinical information holistically including critical thinking skills
- Exceptional verbal and written interpersonal and communication skills
- Ability to work efficiently in a self-management environment
- Solid technical/computer skills
- Excellent documentation skills
- Self-starter with the ability to prioritize daily workload
- Readiness to embrace a fluid, changing, and fast paced environment
Physical and Work Environment:
- Ability to establish a home office workspace
- Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard timeframe
- Ability to communicate with clients and team members including use of cellular phone or comparable communication device
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
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.