Clinical Appeals RN
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come makes 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. The Clinical Appeals RN is responsible for attending appeal hearings, defending MassHealth prior authorization decisions, and performing pre-service/prior authorization clinical coverage review of services. Works closely with managers and peers. If you currently reside in the state of Massachusetts, you’ll enjoy the flexibility to telecommute as you take on some tough challenges.
Requirements
- Associate's degree in Nursing
- Unrestricted RN license required in the state of Massachusetts
- 3+ years of Managed Care and/or clinical experience
- Designated workspace and access to install secure high-speed internet via cable or DSL in home
- Reside in the state of Massachusetts
Nice To Haves
- Prior-Authorization experience
- Utilization Management experience
- Appeals Experience
- Medicare/Medicaid experience preferred
- Proficient with Microsoft Office programs, including Word, Excel, PowerPoint
- Excellent communications skills, including the ability to write clearly, succinctly and in a manner that appeals to a wide audience
- Excellent time management, organizational, and prioritization skills with ability to balance multiple priorities
Responsibilities
- Represent MassHealth at appeal hearings
- Defend MassHealth prior authorization decisions by utilizing program specific regulations, medical necessity guidelines, standards of care and best practices
- Represents the MA MLTSS program in a positive, solution-focused manner that embodies our corporate values: Integrity, Compassion, Relationships, Innovation and Performance
- Determine the appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
- Identify solutions to non-standard requests and problems
- Participate in regular meetings to collaborate with supporting leadership and team to ensure operational efficiency
- Assures performance adheres with established quality standards, evidenced based practice guidelines and departmental benchmarks and workflows
- Act as a resource for others; provide explanations and information on difficult issues
Benefits
- Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
- Medical Plan options along with participation in a Health Spending Account or a Health Saving account
- Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
- 401(k) Savings Plan, Employee Stock Purchase Plan
- Education Reimbursement
- Employee Discounts
- Employee Assistance Program
- Employee Referral Bonus Program
- Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
