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Prior Authorization Clinical Review Coordinator -Remote

Join to apply for the Prior Authorization Clinical Review Coordinator -Remote role at Optum.

Overview

The Clinical Review Coordinator is responsible for reviewing prior-authorization requests for post-acute levels of care. The CRC will review clinical documents and complete reviews based on medical necessity and InterQual criteria. Partners with physicians, providers, and other members of the team to determine the most appropriate level of care for the member.

Primary Responsibilities

Research member benefits and eligibility
Request and review member\'s clinical information from providers
Perform prior authorization reviews on post-acute level of care cases using appropriate clinical criteria; assign to Medical Director for review and decision when applicable; provide determinations to provider and member
Complete all assigned cases within required timeframes (TAT)
Educate providers, members and internal staff on guidelines, member benefits, and alternate levels of care available
Meets performance metrics with goal benchmarks
Process and document all case activities per SOPs, Job Aides, and DES; follows Model of Care guidelines
Acts as a Clinical resource for LPN/LVN and administrative team members
Collaborate with other members of the team to transition the member to an appropriate level of care
Communicate escalations and concerns to Senior ICM/Manager
Identify opportunities for improved communication or processes
Participate in team meetings, compliance meetings, education discussions, and related activities; completes assigned learning timely

Required Qualifications

Active and unrestricted RN license
3+ years total experience including recent clinical experience in an inpatient/acute setting
Experience in acute, long-term acute care, acute rehabilitation, or skilled nursing facilities
Experience in prior-authorization review
Proficient computer skills
Demonstrated high level of organizational skills, self-motivation, and ability to manage time independently
Proven exceptional verbal and written interpersonal and communication skills
Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
Proven ability to quickly adapt to change and drive innovation within the team and market
Proven ability to work across functional areas and businesses to achieve business goals
Proven ability to develop and maintain positive customer relationships
Dedicated work area established that is separated from other living areas and provides privacy
Live in a location that can receive a UnitedHealth Group approved high-speed internet connection

Preferred Qualifications

Bachelor\'s degree
2+ years case management/utilization review
Experience with InterQual and Medicare criteria guidelines
Experience working with Commercial, Medicare, and Medicaid plans
Utilization Review background in managed care

Compensation and Benefits

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to salary, benefits include a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution. The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We are an equal employment opportunity employer and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by law. We are a drug-free workplace; candidates are required to pass a drug test before beginning employment.