Claims Utilization Management Reviewer – Remote in Pacific Time Zone States

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

 

OVERVIEW OF THE POSITION: Responsible for retro review duties that support the retrospective claims review team. This position directly supports the retro review nurse and is designed to gather all needed records/information for the nurse to review. Position will be supported by operational management including the management team within Claim department

This position is full time (40 hours/week) Monday – Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6:00 am – 2:30 pm PST. It may be necessary, given the business need, to work occasional overtime.

We offer 2-3 weeks of on-the-job training. The hours of the training will be aligned with your schedule.

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

 

Primary Responsibilities:

• Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each internal and external customer.
• Reviews medical claims submitted with and without prior authorization to attach medical records
• Engages with claims and clinical claims review functions to discuss trends identified during retrospective claims review.
• Reviews and re-directs inappropriate retro referrals requests to appropriate parties.
• Works with clinical claims review function to ensure compliance with all regulatory requirements. 
• Complies with company and departmental standards for timeliness of review and claims payment to be consistent with regulatory standards related to claims turnaround time.
• Requests medical records in a timely manner in accordance with regulatory/departmental compliance.
• Enters and updates authorizations in computer systems Namm Net Express / Xcelys /CURO
• Requires the ability to work in multiple computer applications simultaneously
• Requires a good knowledge of computer applications such as MS Word, TEAMS, EXCEL
• Practices proper telephone etiquette in handling incoming / outgoing phone calls related to request for referrals.
• Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Performs additional duties as assigned.
• Completion-high school education or higher 

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
• 18 years or older
• 1+ years’ experience in a medical office or claims department
• Knowledge of medical terminology
• Proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications including Microsoft office programs
• Ability to work any of our 8-hour shift schedules during our normal business hours Monday to Friday from 8:00 am to 5:00 pm CST. It may be necessary, given the business need, to work occasional overtime.

 

Preferred Qualifications:

• Knowledge of diagnosis code and CPT coding.
• Strong analytical oral / written problem-solving skills with ability to make sound, independent judgments.  
• Excellent verbal and written communications skills.
• Ability to work with various professionals including members of regulatory agencies, carriers, employers, nurses and health care professionals.
• Ability to act professionally under pressure.

 

Telecommuting Requirements:

• 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.
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

 

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

California, Nevada, Washington, OR Washington, D.C. Residents Only: The hourly range for this is $16.54 – $32.55 per hour. 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.

 

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