Financial Clearance Specialist RN

UnitedHealth Group • Minneapolis, MN

2d • Remote

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

Requirements

• High School Diploma/GED (or higher)
• 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

Nice To Haves

• Bachelor's Degree in Nursing (or higher)
• 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

Responsibilities

• 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 Maintains knowledge of and complies with regulatory requirements, organizational standards, and policies, procedures, and workflows related to areas of responsibility
• Evaluate potential denials or payment issues and initiates communication with physicians or clinician regarding next steps
• Prepare and facilitates 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
• Complete work effectively and efficiently maintaining quality and production standards
• Training/mentoring and daily workflow coaching to less experienced team members on all aspects of the prior authorization process
• Other duties as assigned

Benefits

• In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
• No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED