Role Description

This position is Remote in the states of Washington OR Oregon. You will have the flexibility to work remotely as you take on some tough challenges.

The Pre-authorization Specialist implements, maintains and executes procedures and processes by which Optum performs its referral and authorization process. This position responds to inquiries from patients, staff and physicians pertaining to referral authorization questions. The position also researches medical history and diagnostic tests when requested, to assist in review, processing, and coordination of prospective, concurrent and retrospective referrals.

This position is full-time, Monday - Friday. Employees are required to work during our normal business hours of 7:00am - 4:30pm Monday - Thursday and 8:00am - 12:00pm Friday PST. It may be necessary, given the business need, to work occasional overtime.

We offer on-the-job training. The hours of the training will be aligned with your schedule.

Primary Responsibilities:

• Initiate Referral Authorizations:
• Acquires and maintains a working knowledge of Optum contracted health plans agreements and related insurance products.
• Provides administrative and enrollment support for team to meet Company goals.
• Gathers information from relevant sources for processing referrals and authorization requests.
• Submits authorization & referral requests to health plan via avenue of insurance requirement, including but not limited to website, phone, & fax.
• Tracks authorization status inquiries for timely response.
• Maintains strong understanding of and educates our physicians, clinical teammates, patients and families regarding contracted health plans requirements related to Referrals/Pre-authorization Management.
• Acts as a liaison between providers, teammates, outside vendors, health plans, community services and patients to support Referrals/Pre-authorization management process and requirements.
• Reviews benefit language and medical records to assist in completion of requested services, to meet health plan requirements.
• Documents patient information in the electronic health record following standard work guidelines.
• Coordinates with Clinical teammates and health plans to identify patients with Referrals/Pre-authorization Management needs.
• Provides member services to all patient groups.
• Answers referral and authorization inquiries from health plans, our clinical areas, patients and outside Optum Physician office/facilities.
• Assists in the development and implementation of job specific policy and procedures.
• Assists in the collection of information for member and/or provider appeals of denied requests.
• Identifies areas for potential improvement of patient satisfaction.
• Review Denied Claims (No Authorization/No Referral):
• Researches root causes of missing authorization/referral.
• Processes no authorization, no referral denied claims based on Insurance plans billing guidelines.
• Obtains retro authorizations, appeals denied claims, or writes off charges based on Optum charge write-off guidelines.
• Provides feedback and follow up to clinical areas and appropriate parties.
• Assists in the development and implementation of job specific policies and procedures to reduce no authorization no referral denied claims to increase revenue.
• Initiates improvement in authorization timeliness, accuracy and reimbursement.
• Utilization Management Medical Review:
• Processes Insurance plan referrals in EPIC.
• Utilizes Prior Authorization list, MCG, NCCN, and individual insurance plan medical guidelines/policies to determine administrative review, what is needed for clinical review, and manages the workflows accurately.
• Reviews clinical records to match insurance medical guidelines/policies, acquires additional records if necessary.
• Discusses medical guidelines with insurance plan to reduce referral/prior authorization denial rate, expedite referral authorization process, and to keep peer to peer opportunities to minimal.
• Documents accurately and timely in medical record.
• Processes referrals in timely manner to improve patient’s satisfaction.
• Other duties as assigned.

Qualifications

• High School Diploma / GED OR equivalent years of work experience.
• Must be 18 years of age OR older.
• 1+ years of experience in healthcare, including understanding of health plan related operations.
• Experience in Referrals/Pre-authorization Management/Claims billing.
• Experience with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications.
• Experience with Microsoft Outlook, Microsoft Word & Microsoft Teams.
• Experience with EHR/EMR systems (i.e. Epic).
• Willingness and ability to travel annually for an on-site meeting at the Everett, WA office.
• Ability to work full time. Employees are required to work during our normal business hours of 7:00am - 4:30pm Monday - Thursday and 8:00am - 12:00pm Friday PST. It may be necessary, given the business need, to work occasional overtime.

Preferred Qualifications

• 1+ years of experience in Referrals/Pre-authorization Management.
• 1+ years in appeal writing and processing.
• 1+ years working knowledge of EOB, COB, Remits, and CMS 1500.
• Knowledge of organizational policies, procedures, & systems.
• Working knowledge of CPT & Diagnosis Coding, Medical Terminology, and basic Anatomy.

Telecommuting Requirements

• Reside within the states of Washington OR Oregon.
• 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.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).
• The hourly pay for this role will range from $17.98 - $32.12 per hour based on full-time employment.