Referral Navigator Representative - Kelsey Seybold Clinic - Utilization Review

UnitedHealth Group•Pearland, TX

5d•$18 - $32•Remote

About The Position

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

High School diploma or GED from an accredited program
2+ years of experience in a managed care, utilization management, referral management, care coordination, home health, durable medical equipment (DME), case management, medical office, hospital, health plan, accountable care organization (ACO), or healthcare operations environment
Experience interacting with providers, physicians, clinical staff, healthcare facilities, members, and external vendors regarding healthcare services, authorizations, referrals, or care coordination activities
Experience utilizing electronic medical records (EMR), authorization systems, payer portals, or healthcare information systems
Proven knowledge of medical terminology, healthcare delivery systems, referral management, authorization processes, and care coordination principles
Proven knowledge of medical terminology, CPT & ICD 10 coding, and prior authorization processes

Nice To Haves

Graduate from accredited medical assistant program
5+ years of managed care experience either in a physician office or hospital setting health plan, ACO, or other managed care setting
Experience in creating authorization requests or billing Medicare or private insurance companies

Responsibilities

Serves as a centralized care navigation and coordination resource within the Medical Management Department, supporting referral completion, home health services, durable medical equipment (DME) requests, call center operations, and continuity of care activities across Kelsey-Seybold Clinic and external providers
Performs initial review, triage, and validation of clinical and administrative documentation to ensure requests meet foundational criteria for authorization, physician review, and regulatory processing
Coordinates with physicians, clinics, facilities, home health agencies, providers, members, nurses, medical reviewers, and internal departments to facilitate timely progression of patient care requests and ensure complete communication throughout the continuum of care
Supports the organization’s Closed the Loop program by monitoring and coordinating activities necessary to ensure members receive requested services and that all stakeholders involved in the patient’s care remain informed of outcomes and next steps