Clinical Review Coordinator - National Remote

You'll enjoy the flexibility to telecommute from anywhere within the U.S. 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.
Positions in this function require various professional clinical education, certification and clinical licensure in ancillary clinical roles such as therapist or technician i.e., other than that of physician (MD or DO) or nursing (RN or LPN), based on the specific job posting, job code and grade level. Current, unrestricted licensure in applicable state is required, depending on role and grade level, for therapists (e.g., physical or speech therapists), prosthetists/orthotists, or medical specialty technicians (e.g., sleep lab technicians). Therapists may work under the supervision of an RN or a physician, and technicians work under the supervision of a physician.
Positions are responsible for providing appropriately focused Medical Mgmt Clinical Review of the activities listed below, in support of physician activities, and in accordance with specific review protocols, based on individual member plan documents, national and proprietary coverage review guidelines, and established clinical review guidelines.

• Preservice and Retrospective coverage determinations, and/or
• Appeals for services that have been denied.

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. Under the direct oversight of physicians or RNs, may recommend clinical appropriateness of designated services.
This position is full-time. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00am - 6:00pm 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:

• May have EMR access to mirror inpatient Care Coordinator partner access.
• Complete, ED or HH processes as it related to pre-service authorizations
• Perform review for all direct admits to SNF, IRF, LTAC via physician office, ED or HH
• Participate in the clinical phone queue to ensure customer SLAs are met
• Perform all standard prospective reviews, including patient oral and/or written notifications.
• Partner with Medical Directors for Pre-Service Coordinator training as needed
• Perform all expedited prospective reviews including patient oral and/or written notifications.
• Coordinate peer to peer reviews with navihealth Medical Directors
• Support new delegated contract start-up to ensure experienced staff work with new contracts
• Partner with the full care coordinator team as needed, this may include but is not limited to Operations Leadership, Medical Directors, Skilled Inpatient Care Coordinators, SNF Coordinators, Engagement Specialists and Clinical leadership.
• Educate facilities on the pre-service denial process.
• Perform in a hybrid role as either clinical gatherer and authorization document creator or solely as a clinical and authorization reviewer for all prospective, concurrent and retrospective requests within established parameters.
• Notify hospitals and PAC settings of review outcomes for non-engaged patients
• 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:

• Bachelors Degree (or higher)
• 3+ years of clinical experience
• Active, unrestricted registered clinical license - Registered Nurse, Physical Therapist, or Occupational Therapist
• Ability to work any of our 8-hour shift schedules during our normal business hours of 7:00am - 6:00pm CST. It may be necessary, given the business need, to work occasional overtime to accommodate peaks in volume of work.
• Experience in oversight and supervision of assistants (CNAs, PTAs, OTAs)
• Experience with physician engagement and crucial conversations

Preferred Qualifications:

• ICD-10 and InterQual experience
• Managed Care experience
• Experience performing clinical audits to improve quality standards or performance
• 2+ years of Case Management experience
• CMS knowledge
• Experience working with geriatric population
• Experience in acute care, rehab or skilled nursing facility environment

Telecommuting Requirements:

• 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 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

Soft Skills:

• Strong critical thinking skills and the ability to review patients' clinical information holistically
• Readiness to embrace a fluid, changing, and fast-paced environment
• Ability to work effectively in a self-management environment
• Exceptional verbal and written interpersonal and communication skills
• Self-starter with the ability to prioritize daily workload
• Excellent documentation skills
• Strong technical/computer skills

Physical and Work Environment:

• Ability to establish a home office workspace
• Ability to manipulate laptop computer (or similar hardware) between office and site settings
• Ability to communicate with clients and team members including use of cellular phone or comparable communication device
• Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard time period

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.
California, Colorado, Connecticut, Nevada, New Jersey, New York, Washington or Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / New Jersey / New York / Washington / 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.