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Clinical Review Coordinator Appeals and Denials

3 months ago

Phoenix, United States UnitedHealth Group 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 (Registered Nurse RN, Physical Therapist PT, Occupational Therapist OT or Speech Therapist SLP) 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.

This position is full-time. Schedules are either approximately 8am - 7pm or 9am - 8pm Central Standard Time (CST), Thursday - Sunday. It may be necessary, given the business need, to work occasional overtime. These positions require 4 Holidays per year to be worked on a rotating basis.

We offer weeks of paid training. The hours of the training will be based on schedule or will be discussed on your first day of employment.

You'll enjoy the flexibility to work remotely. from anywhere within the U.S. as you take on some tough challenges. A preference will be given to candidates who reside in Pacific, Mountain or Central time zones.

Primary Responsibilities:

  • Ensure timely processing of all denial- related and member-oriented written communications. Ensure that all denial information is processed according to protocol and that all documentation is timely and meets all Federal and State requirements

  • Ensure second-level reviews have been performed and documented and may confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICC's), Skilled Inpatient Care Coordinators (SICC's), Pre-service Coordinators (PSC's) and facility personnel in determining denial information is processed timely and appropriately

  • Serve as a liaison with regards to communicating to internal and external customers, including health plans, providers, members, quality organizations and other colleagues

  • Document and communicate appeal and denial information via fax, email, or through established portal access, including d appeal and denial letters, NOMNC letters, AOR forms, clinical information

  • Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their team

  • Serve as a liaison for requests for information from QIO or health plan staff

  • Own assigned appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management

  • Complete appeal and denial processes in accordance with CMS and Optum guidelines and compliance policies

  • Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability (including proper grammar, spelling, punctuation, etc.), as well as ability to follow grade-level requirements. (Including, but not limited to DENC letter, IDN letter, Exhaustion of Benefits letter, Administrative Denial letter, Provider Denial letter)

  • Review NOMNC for validity before processing appeal requests

  • Send review to Medical Director for rescinding NOMNC when necessary

  • Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed

  • Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed

  • Follow all established facility policies and procedures

  • Assist with completing pre-service authorization requests to assist the pre-service team as needed

  • Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs

  • 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:

  • High school diploma/GED

  • 3+ years of clinical experience

  • Active, unrestricted registered clinical license - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist

  • Understanding of market variability related to the denial process, specific contractual obligations, and CMS regulations.

  • Experience with Windows and Microsoft Office suite

  • Ability to work any our 8-hour shift schedule during the hours of approximately 8am - 7pm or 9am - 8pm CST, Thursday - Sunday. It may be necessary, given the business need, to work occasional overtime.

  • Ability to work 4 Holidays per year on a rotating basis.

Preferred Qualifications:

  • Managed care experience

  • Case management experience

  • Experience with appeals and/or denials processing

  • Previous utilization management, utilization review, prior authorization related experience

  • ICD-10 experience

  • InterQual experience

  • CMS knowledge

  • Experience determining levels of care

  • For RNs, Compact Nursing License, and multiple state licensures; For Physical Therapy, Compact Licensure and multiple state licensures

  • Residence in Pacific, Mountain or Central time zone

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:

  • Solid technical/computer skills

  • Excellent documentation skills

  • Exceptional verbal and written interpersonal and communication skills

*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 hourly range for this role is $33.75 to $66.25 per hour. 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.

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.