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.SM

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.

This position is full - time, Monday - Friday. Employees are required to work any shift between the hours of 10:00 AM - 7:00 PM CST (Central Standard Time) 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. Training will be conducted virtually from your home.

• All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

• Partner with Medical Directors for Pre - Service Coordinator training as needed
• Perform all standard prospective reviews, including patient oral and / or written notifications
• Perform review for all direct admits to SNF, IRF, LTAC via physician office, ED or HH
• 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
• Support new delegated contract start - up to ensure experienced staff work with new contracts
• Educate facilities on the pre - service denial process
• Perform other duties and responsibilities as required, assigned or requested
• Perform all expedited prospective reviews including patient oral and / or written notifications
• Coordinate peer to peer reviews with navihealth Medical Directors
• Preservice and Retrospective coverage determinations, and / or appeals for services that have been denied
• Positions are responsible for providing appropriately focused Medical Management 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
• Participate in the clinical phone queue to ensure customer SLAs are met
• 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
• Notify hospitals and PAC settings of review outcomes for non - engaged patients
• May have EMR access to mirror inpatient Care Coordinator partner access
• 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
• Complete, ED or HH processes as it related to pre - service authorizations

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:

• Experience with physician engagement and crucial conversations
• 3+ years of clinical experience
• Experience in oversight and supervision of assistants (CNAs, PTAs, OTAs)
• Bachelor’s Degree (or higher)
• Ability to work any shift between the hours of 10:00 AM - 7:00 PM CST (Central Standard Time) from Monday - Friday 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
• Active, unrestricted registered clinical license - Registered Nurse, Physical Therapist, OR Occupational Therapist

Preferred Qualifications:

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

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:

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

Physical and Work Environment:

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

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.

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