Remote Clinical Review Coordinator RN – National


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Requisition Number: 2183964
Job Category: Medical & Clinical Operations
Primary Location: Dallas, TX
(Remote considered)

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere.

As a team member of our naviHealth product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home.

We’re connecting care to create a seamless health journey for patients across care settings. Join our team, it’s your chance to improve the lives of millions while doing your life’s best work.SM

Positions in this function require various professional clinical education, certification, and clinical licensure in ancillary clinical roles such as therapist or technician i.e., other than that of physician (MD or DO) or nursing (RN or LPN), based on the specific job posting, job code and grade level. Current, unrestricted licensure in applicable state is required, depending on role and grade level, for therapists (e.g., physical or speech therapists), prosthetists / orthotists, or medical specialty technicians (e.g., sleep lab technicians). Therapists may work under the supervision of an RN or a physician, and technicians work under the supervision of a physician.

This position is full – time, Monday – Friday. Employees are required to work any shift between the hours of 10:00 AM – 7:00 PM CST (Central Standard Time) including the flexibility and willingness to work occasional overtime (an early or late shift and / or longer than normal hours to accommodate peaks in volume of work) and weekends based on business need.

We offer 12 weeks of paid training. The hours during training will be 10:00 AM – 7:00 PM from Monday – Friday. Training will be conducted virtually from your home.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

  • Perform in a hybrid role as either clinical gatherer and authorization document creator or solely as a clinical and authorization reviewer for all prospective, concurrent and retrospective requests within established parameters
  • Perform review for all direct admits to SNF, IRF, LTAC via physician office, ED or HH
  • Perform all expedited prospective reviews including patient oral and / or written notifications
  • Perform all standard prospective reviews, including patient oral and / or written notifications
  • May have EMR access to mirror inpatient Care Coordinator partner access
  • Coordinate peer to peer reviews with navihealth Medical Directors
  • Notify hospitals and PAC settings of review outcomes for non – engaged patients
  • Partner with Medical Directors for Pre – Service Coordinator training as needed
  • Complete, ED or HH processes as it related to pre – service authorizations
  • Educate facilities on the pre – service denial process
  • Participate in the clinical phone queue to ensure customer SLAs are met
  • Support new delegated contract start – up to ensure experienced staff work with new contracts
  • Partner with the full care coordinator team as needed, this may include but is not limited to Operations Leadership, Medical Directors, Skilled Inpatient Care Coordinators, SNF Coordinators, Engagement Specialists, and Clinical leadership
  • Positions are responsible for providing appropriately focused Medical Management Clinical Review of the activities listed below, in support of physician activities, and in accordance with specific review protocols, based on individual member plan documents, national and proprietary coverage review guidelines, and established clinical review guidelines
  • Preservice and Retrospective coverage determinations, and / or appeals for services that have been denied
  • Uses technical knowledge and related review protocols in the review of clinical information and documents as they relate to company medical policy and benefit document language
  • Under the direct oversight of physicians or RNs, may recommend clinical appropriateness of designated services
  • Perform other duties and responsibilities as required, assigned or requested

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:

  • Bachelor’s Degree (or higher)
  • 3+ years of clinical experience
  • Active, unrestricted, registered clinical license – Registered Nurse, Physical Therapist, OR Occupational Therapist
  • Experience in oversight and supervision of assistants (CNAs, PTAs, OTAs)
  • Ability to work any shift between the hours of 10:00 AM – 7:00 PM CST (Central Standard Time) from Monday – Friday including the flexibility and willingness to work occasional overtime (an early or late shift and / or longer than normal hours to accommodate peaks in volume of work) and weekends based on business need

Preferred Qualifications:

  • 2+ years of Case Management experience
  • Experience in acute care, rehab, OR skilled nursing facility environment
  • Managed Care experience
  • Experience with performing clinical audits to improve quality standards OR performance
  • Experience in working with geriatric population
  • ICD – 10 and InterQual experience
  • CMS knowledge

Telecommuting Requirements:

  • Ability to keep all company sensitive documents secure (if applicable)
  • Required to have a dedicated work area established that is separated from other living areas and provides information privacy
  • Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

Soft Skills:

  • Strong critical thinking skills and the ability to review patients’ clinical information holistically
  • Exceptional verbal and written interpersonal and communication skills
  • Ability to work effectively in a self – management environment
  • Strong technical / computer skills
  • Excellent documentation skills
  • Self – starter with the ability to prioritize daily workload
  • Readiness to embrace a fluid, changing, and fast – paced environment

Physical and Work Environment:

  • Ability to establish a home office workspace
  • Ability to manipulate laptop computer (or similar hardware) between office and site settings
  • Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard time period
  • Ability to communicate with clients and team members including use of cellular phone or comparable communication device

California, Colorado, Connecticut, Nevada, New Jersey, New York, Washington, or Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / New Jersey / New York / Washington / Rhode Island residents is $32.60 – $63.99. 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.