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. , • Ensure all denial information is processed according to protocol and documentation is timely and meets all Federal and State requirements. , • Ensure second-level reviews have been performed and documented. , • 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. , • Serve as a liaison by communicating with internal and external customers including health plans, providers, members, quality organizations, and other colleagues. , • 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. , • Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their teams. , • Serve as a liaison for requests for information from QIO or health plan staff. , • 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. , • Complete appeal and denial processes in accordance with CMS and Optum guidelines and compliance policies. , • Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability. , • Review NOMNC for validity before processing appeal requests. , • Send reviews to Medical Director for rescinding NOMNC when necessary. , • 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. , • Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed. , • Follow all established facility policies and procedures. , • Assist with completing pre-service authorization requests to assist the pre-service team as needed. , • Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs. , • 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. , • 3+ years of clinical experience as a Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist. , • Demonstrated excellent documentation skills. , • Demonstrated exceptional verbal and written interpersonal and communication skills. , • Proficient with Windows and Microsoft Office Suite. , • Ability to work one of the following Monday - Friday schedules: 10am - 7pm Central, 11am - 8pm Central, 12pm - 9pm Central, or 1pm - 10pm Central. , • Ability to work four holidays per year on a rotating basis. , • 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. , • Managed care experience. , • Case management experience. , • Experience processing appeals and/or denials. , • Experience with utilization management, utilization review, or insurance authorizations. , • Experience determining levels of care. , • ICD-10 experience. , • InterQual experience. , • Demonstrated understanding of CMS regulations. , • Demonstrated understanding of the denial process. Benefits • Health and well-being programs and services , • Flexible work schedule and remote-friendly positions , • Health, vision and dental benefits , • HSA and FSA eligible plans , • 401(k) savings plan , • Childcare benefits , • Short-term/ long-term disability coverage , • Basic life insurance and AD&D , • Employee stock purchase plan , • Home office stipend for remote employees Apply Job!