Description
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.**
Position in this function is responsible for performing pre-service clinical coverage review of Day Habilitation services that require review of medical necessity, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of Day Habilitation services following evaluation of medical guidelines and benefit determination.
Generally work is self-directed and not prescribed
Works with less structured, more complex issues
Serves as a resource to others
You'll enjoy the flexibility to work remotely * from anywhere within the U. S. as you take on some tough challenges.
**Primary Responsibilities:**
Assesses and interprets prior authorizations clinical documentation on customer needs and requirements
Identifies solutions to non-standard atypical prior authorization requests and problems
Solves moderately complex problems and/or conducts moderately complex analyses
Works with minimal guidance; seeks guidance on only the most complex tasks
Provides explanations and information to providers on difficult issues
Coaches, provides feedback, and guides others
Acts as a resource for others with less experience
**Functional Competency & Description Proficiency Level**
**Conduct Non-Clinical Research to Support Determinations C) Fully Proficient**
Determine that the case is assigned to the appropriate team for review (e. g., Medicare, Medicaid, Commercial)
Validate that cases/requests for services require additional research
Identify and utilize appropriate resources to conduct non-clinical research (e. g., benefit documents, evidence of coverage, state/federal mandates, online resources)
Prioritize cases based on appropriate criteria (e. g., date of service, urgent, expedited)
Ensure compliance with applicable federal/state requirements and mandates (e. g., turnaround times, medical necessity)
**Revie** **w Existing Clinical Documentation C) Fully Proficient**
Review/interpret clinical/medical records submitted from provider (e. g., office records, test results, prior operative reports)
Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed
Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable
Identify and validate usage of non-standard codes, as necessary (e. g., generic codes)
Apply understanding of medical terminology and disease processes to interpret medical/clinical records
Make determinations per relevant protocols, as appropriate (e. g., approval, denial process, conduct further clinical or non-clinical research)
Review care coordinator assessments and clinical notes, as appropriate
**Conduct Clinical Research to Support Determinations C) Fully Proficient**
Identify relevant information needed to make medical or clinical determinations
Identify and utilize medically-accepted resources and systems to conduct clinical policies, Medical Necessity Guidelines [MNG], state/federal mandates
Review/interpret other sources of clinical/medical information to support clinical or medical determinations (e. g., previous diagnoses, authorizations/denials, case management documentation)
Obtain information from patients, providers and/or care coordinators as needed to verify services rendered and/or recommend additional options
Apply knowledge of applicable state/federal mandates, benefit language, medical/ reimbursement policies and consideration of relevant clinical information to support determinations
Collaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e. g., Medical Directors and their staff, MALTSS program, etc.)
**Make Final Determinations Based on Clinical and Departmental Guidelines C) Fully Proficient**
Demonstrate understanding of business implications of clinical decisions to drive high quality of care
Understand and adhere to applicable legal/regulatory requirements (e. g., federal/state requirements, HIPPA, CMS)
Ask critical questions to ensure member- and customer-centric approach to work
Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
Utilize evidence-based guidelines (e. g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes
Use appropriate business metrics to optimize decisions and clinical outcomesPrioritize work based on business algorithms and established work processes
**Achieve and Maintain Established Productivity and Quality Goals C) Fully Proficient**
Meet/exceed established productivity goals
Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations
Manage/prioritize workload and adjust priorities to meet quality and productivity goals
**Drive Effective Clinical Decisions Within a Business Environment C) Fully Proficient**
Ask critical questions to ensure member/customer centric approach to work
Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as needed
Utilize evidence-based guidelines (e. g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
Identify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performance
Understand and operate effectively/efficiently within legal/regulatory requirements
Compensation Information:
$54.95 / Hourly - $54.95 / Hourly
Starting At: 54.95 Hourly
Up To: 0.0 Hourly
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