Remote Home Health Clinical Review Coordinator, Queensbury, NY


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Requisition Number: 2178386
Job Category: Medical & Clinical Operations
Primary Location: Queensbury, NY
(Remote considered)

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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life’s best work.SM

The Home Health Care Coordinator (HHCC) is responsible for the management of authorization requests for home health services in accordance with CMS and nationally recognized standards. As a member of the Home Health team, the HHCC reviews clinical documentation from home health providers and evaluates the medical necessity of requests for services by utilizing InterQual or internally developed clinical criteria. As necessary, the HHCC collaborates with naviHealth Medical Directors and/or health plan care management staff to determine the most appropriate course of action for a member based on clinical factors.

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

Primary Responsibilities:

  • Document requests for authorization for home health into naviHealth’s clinical documentation system
  • Review OASIS documentation and clinical notes from providers and utilize InterQual criteria to determine medical necessity and appropriate authorization for home health services
  • Understand and apply CMS Chapter 7 guidelines for home health
  • Follow up with providers as necessary for clarification of clinical documentation of patients’ status
  • Collaborate with intake team, home health team, appeals/denials teams, and Medical Directors to ensure efficient processing of home health authorization requests in accordance with mandated turnaround times and quality metrics
  • Notify the health care provider of denials reviewed by the Medical Director
  • Participate in the regular review of departmental reports on key quality metrics and identify opportunities for systemic improvement
  • Maintain active clinical licensure in state of residence and knowledge of nationally recognized utilization management, CMS home health regulations, NCQA and URAC standards of practice
  • Attend naviHealth meetings as requested
  • Adhere to organizational, departmental, and regulatory policies and procedures
  • Promote a positive attitude and work environment
  • Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business
  • Perform other duties and responsibilities as required, assigned, or requested
  • Must be able to work 10:00 am to 7 pm CST

What are the reasons to consider working for UnitedHealth Group?   Put it all together – competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

  • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
  • Medical Plan options along with participation in a Health Spending Account or a Health Saving account
  • Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
  • 401(k) Savings Plan, Employee Stock Purchase Plan
  • Education Reimbursement
  • Employee Discounts
  • Employee Assistance Program
  • Employee Referral Bonus Program
  • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
  • More information can be downloaded at:

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:

  • Active, unrestricted registered clinical license in state of residence – Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist
  • 1+ years of experience in geriatric care management in a home health setting
  • Intermediate level of proficiency with Microsoft Office applications including Outlook, Word, Excel, and PowerPoint

Preferred Qualifications:

  • 2+ years of recent experience in utilization management role
  • 2+ years of experience in an acute care setting
  • 2+ years of wound care experience
  • Knowledgeable of ICD-10 coding
  • Knowledgeable with NCQA and URAC standards
  • Proficient in medical terminology

Soft Skills:

  • Proven documentation skills
  • Proven ability to use various office equipment, such as e-fax and telephone system
  • Independent problem identification/resolution and decision-making skills
  • Proven excellent written skills and oral communication skills to complete the role telephonically
  • Demonstrated ability to be detail oriented and able to prioritize, plan, and handle multiple tasks/demands simultaneously

Work Conditions and Physical Requirements:

  • 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 period of time
  • Ability to communicate with clients and team members including use of cellular phone or comparable communication device
  • Ability to remain stationary for extended time periods (1 – 2 hours)

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

California, Colorado, Nevada, Connecticut, New York City, NY, New Jersey, Rhode Island or Washington Residents Only: The hourly range for California, Colorado, Nevada, Connecticut, New York City, NY, New Jersey, Rhode Island, or Washington residents is $32.60 to $63.99 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.