Specialty Navigator II

UnitedHealth Group•Norwood, MA

18h•Hybrid

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. Reporting to and working under the general direction of the Supervisor(s) and Manager of the department, reviews complex referral requests and evaluates and assigns appropriate specialists for the patient. Works with patients and providers to understand services being requested. Interviews patients as needed to obtain full understanding of what information is being requested. Works closely with Specialty Nurses to ensure clinical handoffs are safe and appropriate. Coordinates care both within Atrius Health and with external partners. Schedule: FT, 40 hours. Monday – Friday, 8:30am – 5pm. This is a hybrid role, hybrid schedule to be determined by manager upon hire. Location: 1177 PROVIDENCE HWY NORWOOD, MA 02062 If you are located within a commutable distance to our Norwood, MA office, you will have the flexibility to work a hybrid schedule as you take on some tough challenges.

Requirements

High School Diploma/GED
3+ years of experience in a clinical or healthcare setting
Intermediate level proficiency in Microsoft, scheduling software and electronic medical records systems (Epic or equivalent)

Nice To Haves

Strong problem solving and complex patient management skills
Relevant experience in the managed care environment
High level of understanding of health insurance products and limitations in order to match patient to available providers.
Bilingual

Responsibilities

Reviews referral information from clinicians for pertinent information regarding tests, consultations, and procedures.
Verifies demographics and insurance information.
Work is highly complex and detail oriented, involving frequent contact with a range of internal and external contacts as well as the need to understand terms and processes of multiple payers
Reviews referral information from work queue for pertinent information regarding referral requests
Conduct detailed reviews of specialty referral requests for opportunity to convert to internal referral in collaboration with clinical team members, ensuring alignment with organizational referral guidelines
Explains insurance benefits and options to patients.
Explains denials to patients.
Keeps patient informed of status of all referrals (approved and denied).
Notifies patients of scheduled appointments and confirms appointment by mail including confirmed location and map of destination.
Informs patient of any preparation that must be completed prior to the appointment.
Contacts patient if insurance coverage issues arise during the referral process so that patient can work directly with the insurance company.
Manage complex patient interactions related to referral decisions, effectively de‑escalating concerns while maintaining adherence to clinical and organizational standards
Promotes the Atrius Health System of Care by highlighting internal providers and their expertise
As needed, places orders to start the referral process for the PCP on behalf of patients who have booked appointments and call for the referral
Researches the visit notes to determine if a referral was intended as well as processing referrals for follow-up or annual visits that require a referral
Schedules patients for tests, consultations, services and procedures with other departments, local private offices, and/or outside vendors/providers
Answers phone calls, faxed requests and other inquires relating to referrals and communicates with the physicians and clinicians to acquire authorization or to inform them of patient issues or clinical paperwork needed
Research questions/concerns from patients regarding bills and determines if issue is related to the referral process.
Assists in resolving billing and denied referral matters as they relate to the referral process.
Refers patients to appropriate staff (e.g., patient account representatives) for billing issues related to insurance benefits and services covered under the benefits plan
Works in collaboration with the person designated as the Practice’s Benefits Coordinator to maintain cost control, ensure that services provided are within benefit plan guidelines, and that necessary policies and procedures are followed when dealing with non-preferred providers/vendors.
May coordinate second opinion requests
Works with supervisors to ensure patients are receiving timely responses and detailed answers to their complex questions
Research questions/concerns from patients regarding billing and determines if issue is related to the referral process.
Assists in resolving billing and denied referral matters as they relate to the referral process.
Receives escalated issues and stat same day calls; determine appropriate action and/or works with clinical team for decision
Effectively deescalates issues with upset patients and practices.
Uses advanced listening techniques to understand the issue and give patients options as they are available.
Escalates to supervisors only as needed
Supports roles within the Navigator.
Trains and teaches as needed
Participates in problem solving activities, focusing on productivity and quality.
Works with supervisors to ensure continuous improvement of the department
If needed, contacts appropriate parties to obtain referral authorizations and verify coverage (e.g., the Authorization Services Unit (ASU), National Imaging Associates (NIA) or individual insurance companies).
Certain departments may also need to contact additional outside agencies for approval (e.g., American Imaging Management or Med Solutions)
Accesses only the minimum necessary protected health information (PHI) for the performance of job duties.
Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc.) taking reasonable precautions to prohibit unauthorized access.
Complies with all Atrius Health and departmental privacy policies, procedures and protocols.
Follows HIPAA privacy guidelines without deviation when handling protected health information
Ability to work in a busy office environment with frequent deadlines and interruptions
Performs other duties as assigned

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.)
incentive and recognition programs
equity stock purchase
401k contribution