Utilization Management Specialist I, Remote - Seattle, WA

The Business Services department is seeking an Utilization Management Specialist I to join their team full time working out of Seattle, WA. Remote option available (must be willing to go to Seattle location if/when network issues arise). Must be located in Washington State.

Optum has clinics in many locations, this job description is not limited to The Everett Clinic and The Polyclinic but may include other medical facilities under Optum.

The Utilization Management Specialist I implements, maintains and executes procedures and processes by which TEC performs its referral and authorization process. This position responds to inquiries from patients, staff and physicians pertaining to managed care benefits and referral authorization status. In addition, this position sends out confirming copies of referrals, authorizations or denial letters as required by health plan guidelines. The position also researches medical history and diagnostic tests when requested, to assist in review, processing, and coordination of prospective, concurrent and retrospective referrals.

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Acquires and maintain 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
• Track authorization status inquires for timely response
• Maintains strong understanding of and educate our physicians, clinical teammates, patients and families regarding contracted health plans requirements related to Utilization Management and authorizations.
• Acts as a liaison between providers, teammates, outside vendors, health plans, community services and patients to support Utilization 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 Utilization Management needs
• Provides member services to all patient group
• 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
• 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.

PREFERRED QUALIFICATIONS:

Note that these requirements are representative, but not all-inclusive, of the knowledge, skill, and ability required to perform this job.

Knowledge: Knowledge of organizational policies, procedures, & systems. Knowledge of EPIC, Microsoft Word, Excel and Code link. Knowledge of anatomy and medical terminology. Knowledge of ICD-10 and CPT coding.

Skills: Excellent written and verbal communication skills.

Abilities: Ability to work effectively with teammates, patients, the public and external agencies. Ability to exercise initiative, problem-solving and decision-making.

Education: High School Diploma, or GED required. Associates or higher education preferred.

Experience: Minimum of two (2) years experience in health care, including understanding of health plan related operations. Experience in Utilization Management is preferred

Certificate/License: Certification from WA State Department of Health as a Medical Assistant-Certified preferred. Certified Professional Coder (CPC) or equivalent preferred.

Requirements:

Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation.