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Clinical Review Coordinator - Remote

Company: UnitedHealth Group
Location: Hartford
Posted on: September 22, 2022

Job Description:

You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Energize your career with one of Healthcare's fastest growing companies. - - You dream of a great career with a great company - where you can make an impact and help people. - We dream of giving you the opportunity to do just this. - And with the incredible growth of our business, it's a dream that definitely can come true. Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. - We live for the opportunity to make a difference and right now, we are living it up. This opportunity is with one of our most exciting business areas: Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 5 leader. Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance. This position is full-time, Thursday to Sunday. Employees are required to have flexibility to work a preset 8-hour shift between the hours of 8:00am - 12:00am CST. 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)
    • 3+ years of clinical experience
    • Proficient with Microsoft Office applications including Word and Excel
    • Understanding of market variability related to the denial process, specific contractual obligations, and CMS regulations
    • Active, unrestricted registered clinical license - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist
    • Ability to work a preset 8-hour shift between the hours of 8:00am - 12:00am CST, Thursday - Sunday.
      Preferred Qualifications:
      • Managed care experience
      • Experience with appeals and/or denials processing
      • Current knowledge of multiple naviHealth contracts
      • ICD-10, and InterQual experience a plus and CMS knowledge
      • 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:
          • Excellent documentation skills
          • Strong technical/computer skills
          • Self-starter with the ability to prioritize daily workload
          • Exceptional verbal and written interpersonal and communication skills
            UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status. Military & Veterans find your next mission: We know your background and experience is different and we like that. UnitedHealth Group values the skills, experience and dedication that serving in the military demands. In fact, many of the values defined in the service mirror what the UnitedHealth Group culture holds true: Integrity, Compassion, Relationships, Innovation and Performance. Whether you are looking to transition from active duty to a civilian career, or are an experienced veteran or spouse, we want to help guide your career journey. Learn more at https://uhg.hr/transitioning-military Learn how Teresa, a Senior Quality Analyst, -works with -military veterans and ensures they receive the best benefits and experience possible. -https://uhg.hr/vet Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system 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 Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $31.78 to $56.88. The salary range for Connecticut / Nevada residents is $35.00 to $62.45. 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. Keywords: #RPO, #YELLOW

Keywords: UnitedHealth Group, Hartford , Clinical Review Coordinator - Remote, Healthcare , Hartford, Connecticut

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