Requisition Number: 2208948
Job Category: Medical & Clinical Operations
Primary Location: Phoenix, AZ
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. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
Senior Clinical Appeals Specialist will perform medical necessity reviews for Clinical Appeals Unit (CAU). This position will work collaboratively with the Patient Financial Services (PFS), Denials Management, CDI, and coding staff to coordinate case flow, and to provide guidance regarding denial management. Senior Clinical Appeals Specialist will be triaging denials routed to CAU to identify root-causes and will be directing cases to appropriate teams or personnel. This position will also be conducting thorough reviews of the medical records and drafting appeal letters, preparing summaries for peer-to-peer discussions and or ALJ hearings and discussing cases with client clinical teams. This position will support Optum’s increased focus on streamlining outpatient and inpatient client clinical appeals. This position will enable CAU to bridge the gaps between CAU, PFS, coding, denial management, and CDI teams. This role will also serve as a navigator for the process flow as well as taking a lead in identifying opportunities in improving outcomes.
Position is remote, with minimal travel requirement. Occasional overnight travel may be required for meetings or educational opportunities.
If you are located in PST or MST time zones, you will have the flexibility to work remotely* as you take on some tough challenges.
- Responsible for triaging denials (Medical necessity vs. Coding vs. Technical) and identifying the root-cause
- Responsible for conducting reviews and responding to insurance denials. Writes concise, factual letters and provides medical record documentation to support appeal. Effectively communicates verbally with external and internal customers to ensure argument for appeal is clearly presented. Responsible for the denials process, including subsequent appeal to health insurance
- Assures appropriate action is taken within appeal time frames to address denials received by CAU
- Collaborates with other departments/resources/entities as applicable to ensure the most optimal appeal outcome
- Utilizes appropriate applications (MIDAS +, Veracity, Artiva, eFR, Sorian EDM) to accurately track clinical denial data; participates in the development and implementation of a system-wide process for appeals
- Experience in using hospital applications including but not limited to EMR (Cerner, Meditech, etc.), Encoders, and CDM tools
- Has extensive knowledge of applicable Medicare, Medicaid, or Commercial determinations and policies, including Local Coverage Determinations (LCD/LCA), National Coverage Determinations (NCD), Policy Bulletins, etc.
- Ability to accurately apply utilization review criteria (InterQual and MCG) when necessary
- Assists with continuous quality improvement of the established appeals process
- Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, discharge disposition, CPT/HCPCS in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance
- Works in conjunction with multiple units including CDI, coding, legal, Mid/Back rev cycle teams, Providers, payers, and other vendors
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.
- Medical school graduate, physician assistant, nurse practitioner or registered nurse (MD, DO, MBBS, PA, NP, or RN). Current, unrestricted RN license for RN applicants
- 2+ years of experience preparing appeals for clinical denials or writing clinical denials on behalf of payers/providers
- 1+ years of experience in outpatient/inpatient coding reviews OR having a coding certification from AAPC or AHIMA
- Solid knowledge of medicine and pathophysiology with understanding of clinical criteria and treatment of medical diagnoses
- Sound knowledge of principals and basics of charging, medical billing, and reimbursement
- Clinical discernment/critical thinking skill to identify what defines the patient encounter
- Excellent written communication skills with the ability to clearly articulate ideas and arguments in a letter
- Solid verbal communication and organization skills
- Proficient in PC use, Microsoft applications (Word, Excel, PowerPoint) and working knowledge of hospital department computer systems
- Ability to be flexible on work hours e.g. switch between Monday to Friday and Tuesday to Saturday schedules as workload requires from time to time
- Certification in Clinical Documentation Improvement (CCDS or CDIP)
- CDI experience
- Project management experience
- Case management experience
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington residents is $70,200 to $137,800 annually. 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.
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