Prior Authorization Clinical Review Coordinator -Remote
About the position Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Clinical Review Coordinator is responsible for reviewing prior-authorization requests for post-acute levels of care. The CRC will review clinical documents and complete reviews based on medical necessity and InterQual criteria. Partners with physicians, providers, and other members of the team to determine the most appropriate level of care for the member.
Responsibilities
- Research member benefits and eligibility
- Request and review member's clinical information from providers
- Perform prior authorization reviews on post-acute level of care cases using appropriate clinical criteria; assign to Medical Director for review and decision when applicable; provide determinations to provider and member
- Complete all assigned cases within required timeframes (TAT)
- Educate providers, members and internal staff on guidelines, member benefits, and alternate levels of care available
- Meets performance metrics with goal benchmarks
- Process and document all case activities per SOPs, Job Aides, and DES; follows Model of Care guidelines
- Acts as a Clinical resource for LPN/LVN and administrative team members
- Collaborate with other members of the team to transition the member to an appropriate level of care
- Communicate escalations and concerns to Senior ICM/Manager
- Identify opportunities for improved communication or processes
- Participate in team meetings, compliance meetings, education discussions, and related activities; completes assigned learning timely Requirements
- Active and unrestricted RN license
- 3+ years total experience including recent clinical experience in an inpatient/acute setting
- Experience in acute, long-term acute care, acute rehabilitation, or skilled nursing facilities
- Experience in prior-authorization review
- Proficient computer skills
- Demonstrated high level of organizational skills, self-motivation, and ability to manage time independently
- Proven exceptional verbal and written interpersonal and communication skills
- Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
- Proven ability to quickly adapt to change and drive innovation within the team and market
- Proven ability to work across functional areas and businesses to achieve business goals
- Proven ability to develop and maintain positive customer relationships
- Dedicated work area established that is separated from other living areas and provides privacy
- Live in a location that can receive a UnitedHealth Group approved high-speed internet connection Nice-to-haves
- Bachelor's degree
- 2+ years case management/utilization review
- Experience with InterQual and Medicare criteria guidelines
- Experience working with Commercial, Medicare, and Medicaid plans
- Utilization Review background in managed care Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
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