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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)

The Utilization Management Specialist implements, maintains and executes procedures and processes by which Optum performs its referral and authorization process. This position responds to inquiries from patients, staff and physicians pertaining to referral authorization questions. The position also researches medical history and diagnostic tests when requested, to assist in review, processing, and coordination of prospective, concurrent and retrospective referrals.

Primary Responsibilities:

• Initiate Referral Authorizations
  • Acquires and maintain a working knowledge of Optum contracted health plans agreements and related insurance products
  • Provides administrative and enrollment support for team to meet Company goals
  • Gathers information from relevant sources for processing referrals and authorization requests
  • Submits authorization & referral requests to healthplan via avenue of insurance requirement. Including but not limited to website, phone, & fax
  • Track authorization status inquires for timely response
  • Maintains solid understanding of and educate our physicians, clinical teammates, patients and families regarding contracted health plans requirements related to Utilization Management and authorizations
  • Acts as a liaison between providers, teammates, outside vendors, health plans, community services and patients to support Utilization Management process and requirements
  • Reviews benefit language and medical records to assist in completion of requested services, to meet health plan requirements
  • Documents patient information in the electronic health record following standard work guidelines
  • Coordinates with Clinical teammates and health plans to identify patients with Utilization Management needs
  • Provides member services to all patient group
  • Answers referral and authorization inquiries from health plans, our clinical areas, patients and outside Optum Physician office/facilities
  • Assists in the development and implementation of job specific policy and procedures
  • Assists in the collection of information for member and/or provider appeals of denied requests
  • Identifies areas for potential improvement of patient satisfaction
• Review Denied Claims (No Authorization/No Referral)
  • Researches root causes of missing authorization/referral
  • Processes no authorization, no referral denied claims based on Insurance plans billing guidelines
  • Obtains retro authorizations, appeals denied claims, or writes off charges based on Optum charge write-off guidelines
  • Provides feedback and follow up to clinical areas and appropriate parties
  • Assists in the development and implementation of job specific policies and procedures to reduce no authorization no referral denied claims to increase revenue
  • Initiates improvement in authorization timeliness, accuracy and reimbursement
• Utilization Management Medical Review:
  • Processes Insurance plan referrals in EPIC
  • Utilizes Prior Authorization list, MCG, NCCN, and individual insurance plan medical guideline to determine administrative review, what is needed for clinical review, and manages the work flows accurately
  • Reviews clinical records to match insurance medical guidelines, acquires additional records if necessary
  • Discuss medical guidelines with insurance plan to reduce referral/prior authorization denial rate, expedite referral authorization process, and to keep peer to peer opportunities to minimal
  • Document accurately and timely in medical record
  • Processes referrals in timely manner to improve patient’s satisfaction
    

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, or higher OR equivalent
• 2+ years of experience in healthcare, including understanding of health plan related operations
• Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifications:

• Associates or Bachelor’s degree
• Experience in Utilization Management
• Intermediate level of experience with Microsoft Suite
• Knowledge of organizational policies, procedures, & systems. Knowledge of EPIC, Microsoft Suite (Word, Excel, Outlook, etc)
• Knowledge of anatomy and medical terminology
• Knowledge of ICD-10 and CPT coding
  

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

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.