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Clinical Review Coordinator

3 months ago

Eden Prairie, United States Optum Full time

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.

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.


The Pre-Service/Clinical Review Coordinator is responsible for reviewing and determining medical appropriateness of pre-authorization requests following evaluation of medical guidelines. The position coordinates the transition of patients from the community or acute setting to the next appropriate level of care.

This position is full-time, Monday to Friday, 10:00am - 7:00pm Central Time and requires 4 holidays to be worked per year on a rotating basis. It may be necessary, given the business need, to work occasional overtime.

***You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.***

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 Registered Nurse, Physical Therapist, or Occupational Therapist
  • 3+ years of clinical experience as an RN, OT, PT
  • 2+ years of case management and/or utilization management experience
  • Clinical experience in acute care, acute inpatient rehabilitation hospital, long-term acute care, or skilled nursing facility settings
  • Experience in working with geriatric population
  • Ability to work the shift hours of Monday - Friday: 10:00am to 7:00pm CST, including some holidays and the occassional overtime based on business need
  • Dedicated, distraction-free space in home for home office with access to high-speed internet

Preferred Qualifications:

  • Bachelor's degree or equivalent experience
  • Managed Care experience
  • Experience with performing clinical audits to improve quality standards or performance
  • Telephonic queue experience
  • Knowledge and experience working with ICD-10 codes and InterQual
  • Knowledge and experience with CMS guidelines

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, or Washington, D.C. Residents Only: The salary range for this role is $70,200 to $137,800 annually. 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.