Specialty Navigator – Surgery Prior Authorization

UnitedHealth Group • Worcester, MA

4d • $18 - $32 • 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.
Reporting to and working under the general direction of the Supervisor(s) and Manager of the department, the Specialty Navigator reviews and processes inpatient or outpatient surgical cases. Works with patients and providers to understand services being requested. Works closely with Specialty Nurses to ensure clinical handoffs are safe and appropriate.
Schedule (FT, 38.75 hours/week): Monday – Friday 8:30am – 5pm EST or 8:00am – 4:30pm EST
If you reside within the state of Massachusetts, you will enjoy the flexibility to telecommute as you take on some tough challenges.

Requirements

• High School Diploma/GED
• 1+ years of receptionist, admin support, or healthcare-related experience
• Experience with Medical Terminology and CPT Codes
• Intermediate level of proficiency with MS Office tools
• Must reside in Massachusetts

Nice To Haves

• 1+ years of experience working in a medical office position performing duties such as scheduling appointments, checking patients in/out, insurance verification, collecting co-pays and maintaining medical records
• Proficiency in Microsoft Office (Word, Excel and Outlook)
• Knowledge of Epic EMR software
• Ability to learn new software (EPIC/EMR) and flexibility to attend new hire training

Responsibilities

• Reviews referral information from clinicians for pertinent information regarding surgeries
• 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 surgical requests
• Ensures adequate information is obtained and relayed when care is moved
• Explains insurance benefits and options to patients
• Explain denials to patients. Keeps patient informed of status of all referrals (approved and denied)
• Notifies patients of scheduled appointments and confirms appointments by mail including confirmed location and map of destination
• Inform patients of any preparation that must be completed prior to the appointment
• Contact patient if insurance coverage issues arise during the referral process so that patient can work directly with the insurance company
• Promotes the Reliant and Atrius Health System of Care by highlighting internal providers and their expertise
• Answers phone calls, faxed requests and other inquiries 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
• 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, contact 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)
• Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations
• Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance
• Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents
• Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeking assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager
• Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers
• Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers
• Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations
• Teamwork: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members
• Complies with health and safety requirements and with regulatory agencies
• Complies with established departmental policies, procedures, and objectives
• Enhances professional growth and development through educational programs, seminars, etc.
• Attends a variety of meetings, conferences, and seminars as required or directed
• Regular, reliable and predictable attendance is required
• Performs other similar and related duties as required or directed

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.)

What This Job Offers

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