[Hiring] Financial Clearance Specialist RN @UnitedHealth Group

Role Description

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.

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

• Identify requirements to obtain prior authorization denials for Oncology services and other medical specialties as needed.
• Prioritize work per Financial Clearance Service Level Agreements (SLA) and payer deadlines to ensure all patients are cleared per standards in system policies.
• Identify prior authorization requirements for service(s) by using tools, electronic resources (i.e. electronic queries, payer websites) and/or phone/fax.
• Complete daily assignments per leadership direction.
• Assess clinical data from medical records to obtain authorization for scheduled services.
• Abstract and submit clinical data from medical records to insurance payers.
• Utilize clinical screening criteria and reviews insurance payer medical policies to ensure patients meet medical necessity for scheduled services.
• Assure the medical record has the proper physician clinical documentation to support medical necessity for the ordered service.
• Monitor for continued authorization, communicates results and opportunities to nurses, physicians, finance, case managers and payers.
• Complete work effectively and efficiently maintaining quality and production standards.
• Maintain knowledge of and comply with regulatory requirements, organizational standards, and policies, procedures, and workflows related to areas of responsibility.
• Evaluate potential denials or payment issues and initiate communication with physicians or clinician regarding next steps.
• Prepare and facilitate appeals for denied claims, as appropriate.
• Escalate peer to peer requests to the ordering physician, and provide appropriate insight to the provider regarding clinical documentation to support medical necessity for the ordered service.
• Summarize denial trends and report to leadership.
• Training/mentoring and daily workflow coaching to less experienced team members on all aspects of the prior authorization process.
• Other duties as assigned.

Qualifications

• High School Diploma/GED
• Active licensed Registered Nurse in the state in which you reside
• 3+ years of Managed Care and/or clinical experience
• 2+ years of experience in an acute hospital or medical clinic setting

Requirements

• Bachelor's Degree in Nursing
• 2+ years of health insurance authorization experience
• 2+ years of experience using InterQual, MCG, or other clinical criteria
• Certified Case Manager (CCM)
• Knowledge of Milliman Criteria

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)

Company Description

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.