Prior Authorization Clinical Reviewer RN - Remote PST

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 Prior Authorization Clinical Reviewer plays an integral role in optimizing the patient’s recovery journey. The Prior Authorization Clinical Reviewer is responsible for reviewing pre-authorization requests for skilled nursing and rehabilitative services and determining if requests meet medical necessity for the requested level of care. The position coordinates the transition of patients from the community or acute setting to the next appropriate level of care while following established facility policies and procedures. If you live in Pacific Time Zone (PST), you will have the flexibility to work remotely as you take on some tough challenges. 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.

Responsibilities

• 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
• Perform review for all direct admits to SNF via physician office, ED or HH
• Perform all expedited prospective reviews, including patient oral and/or written notifications
• May have EMR access to mirror Inpatient Care Coordinator partner access
• Coordinator peer to peer reviews with Medical Directors
• Notify hospitals and SNFs of review outcomes for non-engaged patients
• Partner with Medical Directors for Pre-Service Coordinator training as needed
• Complete processes as it relates to pre-service authorizations
• Educate facilities on the pre-service denial process
• Participate in the clinical phone queue to ensure customer SLA’s are met
• Support new delegated contract start-up to ensure experienced staff work with new contracts

Requirements

• Active, unrestricted Registered Nurse license in state of residence
• Resides in the Pacific Time Zone
• 3+ years of clinical experience
• Experience with physician engagement and crucial conversations
• Ability to work the weekly assigned shift: Monday-Friday 8a-5p PT
• Required to work holiday rotations, at least 3+ holidays per year
• Ability to work any shift including 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
• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Nice-to-haves

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

Benefits

• a comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

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