Clinical Consultant - Remote

UnitedHealth Group•Minneapolis, MN

3d•$72,800 - $130,000•Remote

About The Position

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together The Clinical Consultant is responsible for reviewing large claim notices to identify potential risks, setting up and monitoring claimants in POWER, and notifying relevant stakeholders as risk levels change. The role also involves educating internal and external customers about clinical trends, researching disease states using reputable resources, and assessing opportunities for cost containment. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Current and unrestricted RN license in the state of residence
5+ years of clinical experience
2+ years of ER, critical care or oncology experience
2+ years of experience working in an insurance or managed care company, or working with a third-party administrator
Proficient in Microsoft Excel

Nice To Haves

Employer Stop Loss experience
Computer proficiency, specifically solid typing skills and Internet research skills
Demonstrated ability to multitask and remain organized

Responsibilities

Review and assess large claim notices for potential risks.
Set-up potential large dollar claimants in POWER for ongoing risk assessment and allocation of reserves
Continue to follow these claimants on a monthly or bi-weekly basis depending on the severity and change in treatment
Know when to set these claimants up based on clinical and cost knowledge
Complete review of LCNs within 48 business hours of receipt
Notify underwriter and claims auditor of potential risk when first notice received and again as risk changes
Educate non-medical internal and external customers regarding clinical trends, treatments, possible outcomes
Research medical conditions and disease states for appropriate treatment for specific conditions
Utilize reputable clinical resources for research as needed such as NCCN, CDC, Predict Dx
Assess all claimants for potential cost containment opportunities.
Collaborate with TPA, case manager, claims auditor, underwriter, vendor to discuss and place appropriate cost containment measures
Maintain timely diary follow-up of all claimants open in POWER.
Index all documentation received
Co-manage complex medical cases with Transplant/Dialysis coordinator
Provide clinical claim file review for claims auditor as needed.
Perform appropriate research for each clinical claim file review request
Provide discussion/answer questions for claims auditor as needed
Perform experimental/investigational file reviews for Claims
Review PYCS to assist claim auditor in setting appropriate reserves based on known or anticipated cost
Reviewed all documents indexed into the package for each cost estimator request
Perform appropriate research for each cost estimator request
Identify all actual and potential risks for each cost estimator request
Document clinical summary and estimate cost of care for each individual identified as at risk
Provide re-review of additional information for updated cost estimates as needed
Complete requests for cost estimates on new business within 24 business hours of receipt and on renewal business within 48 business hours of receipt
Provide discussion/answer questions for underwriter as needed
Complete Hot Claims reports as needed. This is used to track large claims and any cost containment strategies put in place
Attend monthly Account Management/Sales calls