Responsible for maintaining and managing the internal and external utilization processes in a timely and accurate manner consistent with Optum’s policies and procedures as described in the Utilization Management Plan. ESSENTIAL FUNCTIONS:Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer. Performs effective prospective and concurrent revi... more details
OVERVIEW OF POSITION:
Responsible for maintaining and managing the internal and external utilization processes in a timely and accurate manner consistent with Optum’s policies and procedures as described in the Utilization Management Plan.
ESSENTIAL FUNCTIONS:
- Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
- Performs effective prospective and concurrent review of requested services according to established guidelines and timeframes.
- Documents members’ service benefits by contacting the appropriate health plans as needed.
- Directs providers/members to contracted provider network and facilities.
- Processes appropriate authorizations for HMO/PPO clients as specified in the Optum procedures.
- Prints and mails authorizations to providers, patients, HMOs and facilities as needed.
- Assists and monitors in the processing of referrals. Enters, updates and closes referrals daily while assuring that appropriate internal/external referral providers are utilized, members are eligible and have benefits coverage, correct CPT/ICD-9 codes have been entered, accurate records of all dates and other required fields are entered, supporting clinical data for the referrals is entered, and all urgent referrals are processed within the designated timeframe.
- Processes referrals for durable medical equipment and coordinates home health services according to established policies, procedures and guidelines.
- Processes elective surgical requests including the coordination of surgery dates and notification of inpatient team, Hospitalist or Care Manager when appropriate.
- Coordinates, identifies and routes referrals that require review to licensed Care Management staff who arranges outside physician medical review as appropriate.
- Acts as a resource to other coordinators, staff and providers by resolving issues and responding to requests in a timely and effective manner.
- Works with Patient Services regarding member concerns.
- Processes referrals for inter-facility transfers using pre-established guidelines.
- Processes after-hours emergency/urgent care logs/lists as needed.
- Collects and prepares medical records for review when appropriate or as requested.
- Assists with answering telephones and maintaining files, logs or other reports.
- Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Performs additional duties as assigned.
EDUCATION:
If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work. (SM)
Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers 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. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
