Requisition Number: 2180755
Job Category: Medical & Clinical Operations
Primary Location: Eden Prairie, MN
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.
At OptumHealth, you will perform within an innovative culture that’s focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that’s greater than you’ve ever imagined.
As a Stop Loss Nurse Consultant, you will develop and implement process improvements to help increase company growth. This role provides a nice change from a clinical environment and the chance to learn something new every day!
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
- Review and assess large claim notices for potential risks (approx. 25%)
- Set-up potential large dollar claimants in POWER for ongoing risk assessment and allocation of reserves
- Continue to follow these claimants on a monthly or bi-weekly basis depending on the severity and change in treatment
- Know when to set these claimants up based on clinical and cost knowledge
- Complete review of LCNs within 48 business hours of receipt
- Notify underwriter and claims auditor of potential risk when first notice received and again as risk changes
- Educate non-medical internal and external customers regarding clinical trends, treatments, possible outcomes
- Research medical conditions and disease states for appropriate treatment for specific conditions
- Utilize reputable clinical resources for research as needed such as NCCN, CDC, Predict Dx
- Assess all claimants for potential cost containment opportunities (approx. 20%)
- Collaborate with TPA, case manager, claims auditor, underwriter, vendor to discuss and place appropriate cost containment measures.
- Maintain timely diary follow-up of all claimants open in POWER (10%)
- Index all documentation received
- Co-manage complex medical cases with Transplant/Dialysis coordinator
- Provide clinical claim file review for claims auditor as needed (5%)
- Perform appropriate research for each clinical claim file review request
- Provide discussion/answer questions for claims auditor as needed
- Perform experimental/investigational file reviews for Claims
- Review PYCS to assist claim auditor in setting appropriate reserves based on known or anticipated cost
- Review all documents indexed into the package for each cost estimator request (approx. 40% but during busy season—end of August to December approx. 75%)
- Perform appropriate research for each cost estimator request
- Identify all actual and potential risks for each cost estimator request
- Document clinical summary and estimate cost of care for each individual identified as at risk
- Provide re-review of additional information for updated cost estimates as needed
- Complete requests for cost estimates on new business within 24 business hours of receipt and on renewal business within 48 business hours of receipt
- Provide discussion/answer questions for underwriter as needed
- Complete Hot Claims reports as needed. This is used to track large claims and any cost containment strategies put in place.
- Attend monthly Account Management/Sales calls
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.
- Active and unrestricted RN license in current state of residence
- 5+ years of clinical experience
- Computer proficiency, specifically strong typing skills and Internet research skills, must have a clear understanding of Microsoft Word and Excel
- Demonstrated ability to multitask and remain organized
- Bachelor’s degree
- Experience working in an ER, ICU or Critical Care environment
- Employer Stop Loss experience
- Provider Stop Loss, HMO experience
- Experience working in an insurance or managed care company, or working with a third party administrator
California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $67,800 to $133,100. 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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