Clinical Review Coordinator, Appeals and Denials - Remote US
About the position
The Clinical Review Coordinator for Appeals and Denials at Optum plays a crucial role in transforming healthcare delivery from hospital to home, particularly for older adults. This remote position involves ensuring timely processing of denial-related communications, serving as a liaison between various stakeholders, and documenting appeal and denial information. The role is integral to supporting patients during their transitions across care settings, ultimately contributing to their well-being and access to necessary services.
Responsibilities
Ensure timely processing of all denial-related and member-oriented written communications.
,
Ensure all denial information is processed according to protocol and documentation is timely and meets all Federal and State requirements.
,
Ensure second-level reviews have been performed and documented.
,
Confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICCs), Skilled Inpatient Care Coordinators (SICCs), Pre-service Coordinators (PSCs) and facility personnel to ensure denial information is processed timely and appropriately.
,
Serve as a liaison by communicating with internal and external customers including health plans, providers, members, quality organizations, and other colleagues.
,
Document and communicate appeal and denial information via fax, email, or established portal access, including appeal and denial letters, NOMNC letters, AOR forms, and clinical information.
,
Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their teams.
,
Serve as a liaison for requests for information from QIO or health plan staff.
,
Own assigned appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management.
,
Complete appeal and denial processes in accordance with CMS and Optum guidelines and compliance policies.
,
Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability.
,
Review NOMNC for validity before processing appeal requests.
,
Send reviews to Medical Director for rescinding NOMNC when necessary.
,
Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed.
,
Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed.
,
Follow all established facility policies and procedures.
,
Assist with completing pre-service authorization requests to assist the pre-service team as needed.
,
Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs.
,
Perform other duties and responsibilities as required, assigned, or requested.
Requirements
Active, unrestricted registered clinical license in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist.
,
3+ years of clinical experience as a Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist.
,
Demonstrated excellent documentation skills.
,
Demonstrated exceptional verbal and written interpersonal and communication skills.
,
Proficient with Windows and Microsoft Office Suite.
,
Ability to work one of the following Monday - Friday schedules: 10am - 7pm Central, 11am - 8pm Central, 12pm - 9pm Central, or 1pm - 10pm Central.
,
Ability to work four holidays per year on a rotating basis.
,
Dedicated, distraction-free workspace and the ability to install high speed internet via DSL/Cable Broadband/Fiber at home.
Nice-to-haves
Compact licensure or multiple state licensures.
,
Managed care experience.
,
Case management experience.
,
Experience processing appeals and/or denials.
,
Experience with utilization management, utilization review, or insurance authorizations.
,
Experience determining levels of care.
,
ICD-10 experience.
,
InterQual experience.
,
Demonstrated understanding of CMS regulations.
,
Demonstrated understanding of the denial process.
Benefits
Health and well-being programs and services
,
Flexible work schedule and remote-friendly positions
,
Health, vision and dental benefits
,
HSA and FSA eligible plans
,
401(k) savings plan
,
Childcare benefits
,
Short-term/ long-term disability coverage
,
Basic life insurance and AD&D
,
Employee stock purchase plan
,
Home office stipend for remote employees
Apply Now
The Clinical Review Coordinator for Appeals and Denials at Optum plays a crucial role in transforming healthcare delivery from hospital to home, particularly for older adults. This remote position involves ensuring timely processing of denial-related communications, serving as a liaison between various stakeholders, and documenting appeal and denial information. The role is integral to supporting patients during their transitions across care settings, ultimately contributing to their well-being and access to necessary services.
Responsibilities
Ensure timely processing of all denial-related and member-oriented written communications.
,
Ensure all denial information is processed according to protocol and documentation is timely and meets all Federal and State requirements.
,
Ensure second-level reviews have been performed and documented.
,
Confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICCs), Skilled Inpatient Care Coordinators (SICCs), Pre-service Coordinators (PSCs) and facility personnel to ensure denial information is processed timely and appropriately.
,
Serve as a liaison by communicating with internal and external customers including health plans, providers, members, quality organizations, and other colleagues.
,
Document and communicate appeal and denial information via fax, email, or established portal access, including appeal and denial letters, NOMNC letters, AOR forms, and clinical information.
,
Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their teams.
,
Serve as a liaison for requests for information from QIO or health plan staff.
,
Own assigned appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management.
,
Complete appeal and denial processes in accordance with CMS and Optum guidelines and compliance policies.
,
Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability.
,
Review NOMNC for validity before processing appeal requests.
,
Send reviews to Medical Director for rescinding NOMNC when necessary.
,
Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed.
,
Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed.
,
Follow all established facility policies and procedures.
,
Assist with completing pre-service authorization requests to assist the pre-service team as needed.
,
Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs.
,
Perform other duties and responsibilities as required, assigned, or requested.
Requirements
Active, unrestricted registered clinical license in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist.
,
3+ years of clinical experience as a Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist.
,
Demonstrated excellent documentation skills.
,
Demonstrated exceptional verbal and written interpersonal and communication skills.
,
Proficient with Windows and Microsoft Office Suite.
,
Ability to work one of the following Monday - Friday schedules: 10am - 7pm Central, 11am - 8pm Central, 12pm - 9pm Central, or 1pm - 10pm Central.
,
Ability to work four holidays per year on a rotating basis.
,
Dedicated, distraction-free workspace and the ability to install high speed internet via DSL/Cable Broadband/Fiber at home.
Nice-to-haves
Compact licensure or multiple state licensures.
,
Managed care experience.
,
Case management experience.
,
Experience processing appeals and/or denials.
,
Experience with utilization management, utilization review, or insurance authorizations.
,
Experience determining levels of care.
,
ICD-10 experience.
,
InterQual experience.
,
Demonstrated understanding of CMS regulations.
,
Demonstrated understanding of the denial process.
Benefits
Health and well-being programs and services
,
Flexible work schedule and remote-friendly positions
,
Health, vision and dental benefits
,
HSA and FSA eligible plans
,
401(k) savings plan
,
Childcare benefits
,
Short-term/ long-term disability coverage
,
Basic life insurance and AD&D
,
Employee stock purchase plan
,
Home office stipend for remote employees
Apply Now