Clinical Review Coordinator - Remote in Pacific OR Mountain Standard Time Zone
Company: UnitedHealth Group
Location: Las Vegas
Posted on: September 11, 2023
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Job Description:
If you are located within Pacific OR Mountain Standard Time
zone, you will have the flexibility to telecommute* (work from
home) as you take on some tough challenges.
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.---
This position is full-time, Monday - Friday. Employees are required
to have flexibility to work any of our 8-hour shift schedules
during our normal business hours of 3:00pm - 12:00am CST. It may be
necessary, given the business need, to work occasional
overtime.--
We offer weeks of paid training. The hours during training will be
discussed.
*All Telecommuters will be required to adhere to UnitedHealth
Group's Telecommuter Policy.
Primary Responsibilities:
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:
3+--years of clinical experience--
Active, unrestricted registered clinical license - Registered
Nurse, Physical Therapist, Occupational Therapist, or Speech
Therapist
Understanding of market variability related to the denial process,
specific contractual obligations and CMS regulations
Experience with Windows and Microsoft Office suite
Ability to work any of our 8-hour shift schedules during our normal
business hours of 3:00pm - 12:00am CST, Monday - Friday
Preferred Qualifications:
Case management experience
Managed care experience--
ICD-10, and InterQual experience a plus and CMS knowledge--
For RNs, Compact Nursing License preferred and multiple state
licensures
For Physical Therapy, Compact Licensure preferred 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
Exceptional verbal and written interpersonal and communication
skills
California, Colorado, Nevada, or Washington Residents Only: The
salary range for California / Colorado / Nevada / Washington
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 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.
#RPO #YELLOW
Keywords: UnitedHealth Group, Las Vegas , Clinical Review Coordinator - Remote in Pacific OR Mountain Standard Time Zone, Healthcare , Las Vegas, Nevada
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