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.The Pre-Service Clinical Review Coordinator is responsible for processing prior authorization requests for post-acute care placement by reviewing clinical documentation and determining medical appropriateness based on established medical guidelines. This position helps coordinate the transition of patients from the community or acute setting to the next appropriate level of care.The Pre-Service Clinical Review Coordinator is a remote, full-time position Monday- Friday 10am - 7pm Central Time and requires rotating holiday coverage. Depending on business needs, occasional overtime may be requested.You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.Why naviHealth?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.Primary Responsibilities:
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.Required Qualifications:
Active, unrestricted registered clinical license as a Registered Nurse (RN)
3+ years of clinical experience as an RN in long term acute care (LTAC) and/or inpatient rehab facility (IRF)
Geriatric clinical experience
Proficiency with Microsoft Office products such as Word and Excel
Ability to adapt to and navigate electronic computer programs and platforms
Proven ability to multi-task
Proven solid communication and customer service skills
Ability to work Monday- Friday 10am - 7pm Central Time, rotating holidays, and occasional overtime when needed
Access to a dedicated, distraction-free home office with high-speed internet
Preferred Qualifications:
Bachelor’s degree
Experience in utilization management
Experience reviewing and determining medical appropriateness of prior-authorization requests
Experience performing clinical quality and performance audits
Experience with InterQual and/or Milliman Care Guidelines (MCG)
Telephonic queue experience
Knowledge and experience with CMS guidelines and ICD-10 codes
Reside in Central Time Zone
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter PolicyCalifornia, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington or Washington, D.C. Residents Only: The hourly range for this role is $33.75 to $66.25 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.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.