Claims Utilization Management Reviewer - Remote in Pacific Time Zone States

About the position

The Claims Utilization Management Reviewer position at Optum is responsible for supporting the retrospective claims review team by gathering necessary records and information for the retro review nurse. This role is crucial in ensuring compliance with regulatory requirements and maintaining high standards of customer service. The position offers flexibility to telecommute and requires the ability to work in a fast-paced environment while managing multiple computer applications.

Responsibilities

• Exhibit superior customer service skills with internal and external customers.
• Review medical claims submitted with and without prior authorization to attach medical records.
• Engage with claims and clinical claims review functions to discuss trends identified during retrospective claims review.
• Review and redirect inappropriate retro referral requests to appropriate parties.
• Work with clinical claims review function to ensure compliance with all regulatory requirements.
• Comply with company and departmental standards for timeliness of review and claims payment.
• Request medical records in a timely manner in accordance with regulatory/departmental compliance.
• Enter and update authorizations in computer systems Namm Net Express / Xcelys /CURO.
• Work in multiple computer applications simultaneously.
• Maintain proper telephone etiquette in handling incoming/outgoing phone calls related to requests for referrals.
• Protect and disclose HCP patients' protected health information (PHI) in accordance with HIPAA standards.
• Perform additional duties as assigned.

Requirements

• 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, including Microsoft Office programs
• Ability to work any of the 8-hour shift schedules during normal business hours Monday to Friday.

Nice-to-haves

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

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Flexible work schedule and remote-friendly positions
• Health, vision, and dental benefits
• HSA and FSA eligible plans
• Childcare benefits
• Short-term/long-term disability coverage
• Basic life insurance and AD&D
• Home office stipend for remote employees