Sr Care Advocate - Remote

UnitedHealth Group Inc.•Las Vegas, NV

34d•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 Senior Care Advocate (SCA) plays a key role in supporting the behavioral health needs of our members across multiple lines of business, including Commercial and Medicaid. The SCA is responsible for conducting initial, concurrent reviews, and utilization management for a variety of levels of care, including inpatient, residential, intensive outpatient, and partial hospitalization programs. This position requires solid clinical judgment, organizational skills, and the ability to effectively manage multiple priorities in a fast-paced environment. In addition to clinical work, the SCA will perform critical administrative functions, including reviewing and processing denials, documenting medical necessity, and completing the appeals process in compliance with state, federal, and plan-specific guidelines. You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

RN or Master's degree in social work, or related behavioral health field (LCSW, LPC, MFT etc.)
Active, unrestricted behavioral health license in the state of Nevada
3+ years of behavioral health clinical experience in an inpatient/acute or outpatient setting
Familiarity with Medicaid, and Commercial benefit structures and utilization management protocols
Proficient in using clinical systems, Microsoft Office applications, and electronic documentation platforms
Demonstrated ability to work independently and within a team in a remote or office-based environment
Proven ability to multi-task in a high-volume, deadline-driven setting

Nice To Haves

Experience in managed care or health plan settings
Experience with denials and appeals processing
Solid knowledge of InterQual, MCG, and ASAM criteria

Responsibilities

Conduct utilization reviews for behavioral health services across multiple levels of care using established medical necessity criteria (InterQual, MCG, ASAM, etc.)
Evaluate clinical information and determine medical necessity and level of care using established guidelines and criteria
Proficiently manage cases across various lines of business including Medicaid, HPN, and Commercial
Participate in live rounds with internal teams and/or medical directors to present cases and collaborate on care determinations
Review and process medical necessity and administrative denials and associated documentation with accuracy and timeliness
Complete and manage appeals cases according to required timelines and regulatory standards
Collaborate with other departments to resolve complex member needs and support care transitions
Monitor workload, prioritize tasks effectively, and demonstrate solid time management and multitasking abilities
Adhere to all organizational policies, regulatory requirements, and confidentiality standards