Clinical Review Coordinator, Appeals and Denials - Remote US

About the position

The Clinical Review Coordinator for Appeals and Denials at Optum plays a crucial role in transforming healthcare delivery from hospital to home, particularly for older adults. This remote position involves ensuring timely processing of denial-related communications, serving as a liaison between various stakeholders, and documenting appeal and denial information. The role is integral to supporting patients during their transitions across care settings, ultimately contributing to their well-being and access to necessary services.

Responsibilities
• Ensure timely processing of all denial-related and member-oriented written communications.
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• Ensure all denial information is processed according to protocol and documentation is timely and meets all Federal and State requirements.
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• Ensure second-level reviews have been performed and documented.
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• Confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICCs), Skilled Inpatient Care Coordinators (SICCs), Pre-service Coordinators (PSCs) and facility personnel to ensure denial information is processed timely and appropriately.
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• Serve as a liaison by communicating with internal and external customers including health plans, providers, members, quality organizations, and other colleagues.
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• Document and communicate appeal and denial information via fax, email, or established portal access, including appeal and denial letters, NOMNC letters, AOR forms, and clinical information.
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• Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their teams.
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• Serve as a liaison for requests for information from QIO or health plan staff.
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• Own assigned appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management.
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• Complete appeal and denial processes in accordance with CMS and Optum guidelines and compliance policies.
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• Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability.
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• Review NOMNC for validity before processing appeal requests.
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• Send reviews to Medical Director for rescinding NOMNC when necessary.
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• Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed.
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• Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed.
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• Follow all established facility policies and procedures.
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• Assist with completing pre-service authorization requests to assist the pre-service team as needed.
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• Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs.
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• Perform other duties and responsibilities as required, assigned, or requested.

Requirements
• Active, unrestricted registered clinical license in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist.
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• 3+ years of clinical experience as a Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist.
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• Demonstrated excellent documentation skills.
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• Demonstrated exceptional verbal and written interpersonal and communication skills.
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• Proficient with Windows and Microsoft Office Suite.
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• Ability to work one of the following Monday - Friday schedules: 10am - 7pm Central, 11am - 8pm Central, 12pm - 9pm Central, or 1pm - 10pm Central.
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• Ability to work four holidays per year on a rotating basis.
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• Dedicated, distraction-free workspace and the ability to install high speed internet via DSL/Cable Broadband/Fiber at home.

Nice-to-haves
• Compact licensure or multiple state licensures.
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• Managed care experience.
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• Case management experience.
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• Experience processing appeals and/or denials.
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• Experience with utilization management, utilization review, or insurance authorizations.
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• Experience determining levels of care.
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• ICD-10 experience.
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• InterQual experience.
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• Demonstrated understanding of CMS regulations.
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• Demonstrated understanding of the denial process.

Benefits
• Health and well-being programs and services
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• Flexible work schedule and remote-friendly positions
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• Health, vision and dental benefits
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• HSA and FSA eligible plans
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• 401(k) savings plan
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• Childcare benefits
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• Short-term/ long-term disability coverage
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• Basic life insurance and AD&D
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• Employee stock purchase plan
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• Home office stipend for remote employees

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