Claims Utilization Management Reviewer – Remote in CA or NV

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Responsible for retro review duties that support the retrospective claims review team. This position directly supports the retro review nurse and is designed to gather all needed records / information for the nurse to review. Position will be supported by operational management including the management team within Claim department.

This position is full time, Monday – Friday. Employees are required to have flexibility to work our normal business hours of 6:00 AM – 2:30 PM PST. It may be necessary, given the business need, to work occasional overtime.

We offer 2 – 3 weeks of paid on-the-job training. The hours of training will be aligned with your schedule.

If you are located within the state of California OR Nevada, you will have the flexibility to work remotely as you take on some tough challenges.

Primary Responsibilities:

Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care, and concern with each internal and external customer.

Reviews medical claims submitted with and without prior authorization to attach medical records.

Engages with claims and clinical claims review functions to discuss trends identified during retrospective claims review.

Reviews and re – directs inappropriate retro referrals requests to appropriate parties.

Works with clinical claims review function to ensure compliance with all regulatory requirements.

Complies with company and departmental standards for timeliness of review and claims payment to be consistent with regulatory standards related to claims turnaround time.

Requests medical records in a timely manner in accordance with regulatory/departmental compliance.

Enters and updates authorizations in computer systems Namm Net Express / Xcelys / CURO.

Requires the ability to work in multiple computer applications simultaneously.

Requires a good knowledge of computer applications such as Microsoft Word, Microsoft Excel, Microsoft Teams.

Practices proper telephone etiquette in handling incoming / outgoing phone calls related to request for referrals.

Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

Performs additional duties as assigned.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

High School Diploma / GED

Must be 18 years of age OR older

1 years of experience in a medical office OR claims department

Knowledge of medical terminology

Proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications including Microsoft office programs

Ability to work any shift between the hours of 6:00 AM – 2:30 PM PST from Monday – Friday including the flexibility to work occasional overtime based on business need

Preferred Qualifications:

Knowledge of diagnosis code and CPT coding

Analytical oral / written problem – solving skills with ability to make sound, independent judgments

Verbal and written communications skills

Ability to work with various professionals including members of regulatory agencies, carriers, employers, nurses, and health care professionals

Ability to act professionally under pressure

Telecommuting Requirements:

Reside within the state of California OR Nevada

Ability to keep all company sensitive documents secure (if applicable)

Required to have a dedicated work area established that is separated from other living areas and provides information privacy

Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

California OR Nevada Residents Only: The hourly range for this is $16.54 – $32.55 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment .

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