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　　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.

　　If you are located in Everett and Seattle, WA you will have the flexibility to work remotely*, as well as work in the office as you take on some tough challenges.

　　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.

　　Years of post-high school education can be substituted/is equivalent to years of experience

　　Required Qualifications:

　　High school diploma, GED OR equivalent

　　2+ years of experience in healthcare, including understanding of health plan related operations

　　Preferred Qualifications :

　　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

　　Washington Residents Only: The hourly range for Washington residents is $16.54 to $32.55 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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.