Position Description:

When you are in the business of health care, you're in the business of people. At UnitedHealth Group we want every customer experience to be distinctly personal. The challenge is complex. When people call us for help, their focus is on getting the best care possible. We help them understand their benefits and their options. This part of their lives matters a lot to them and it matters just as much to us. Our customer service teams have a serious responsibility to make every contact informative, productive, positive, and memorable for what it says about how much we care.

Primary Responsibilities:

• Under the general direction of the Clinical director or designee, provides authorizations for hospital Admissions, Skilled Nursing Facilities, Rehabilitation Facilities, Specialist providers, Out Patient Services and Ancillary Services such as Home Health Care, Durable Medical equipments, Orthotics/ Prosthetic Devices, Colostomy Supplies and Infusion Services, and others as directed.
• Assist in the coordination of discharge planning activities on all plan participants. The plan is dependent upon participants discharge needs.
• Communicates with a variety of clinical disciplines to clarify and enforce plan policies and procedures.
• Collects and review of service request for completeness and referral to Clinical Director or Medical Director
• Answer the telephone ACD line as scheduled time.
• Verifies benefits in Diamond System
• Referral filling and distribution to the designee coordinator.
• Referral process for outpatient Services but not limited to outpatient surgeries, Rehabilitation Therapies, Radiation Therapy, Chemotherapy, Provider’s evaluations and follow up, Ancillary Services, such as DME’s, HHC and Orthotics/Prosthetics Devices. Collection of data for clinical oversight.
• Pre-Authorization entering for request of services such as, clinical evaluations/follow up visits, outpatient procedures, Inpatient services such as: Elective admissions, Emergency room admissions, Skilled Nursing Facilities, Rehabilitation Facilities, outpatient services, Ancillary Services, such as DME’s, HHC and Orthotics/ Prosthetics Devices in Diamond System when applicable. Collection of data for clinical oversight
• Daily notification to PCP’S of Admissions authorizations to acute facilities. Authorization entering for plan members under the care of Dialysis and Hospice services.
• Process denial authorizations for non-coverage services for Medicare and Medicaid plan participant’s adherence to timeliness for determinations. 
• Maintain and updates daily reports as required such as but not limited to: Daily Hospital Admission Census, Skilled Nursing Facility Census, Rehabilitation Census, Part B Census, and Home Health Care Census.
• Maintain monthly reports for Dialysis, Hospice, Healthy Start, Medicaid Sterilization, Abortion and Hysterectomy, Re-admission to acute facilities, Admissions to acute facility and Telephone ACD Reports.
• Assist Case Managers and PCPs in the coordination of discharge planning from Acute Facilities to sub acute placements and from Skilled Nursing Facilities and Rehabilitation Facilities to home and to community services.
• Maintain record of discharge planning implemented and coordinated services.
• Send Discharge Notification Form with all discharge planning arrangement to PCPs upon discharge from facilities
• Follow up with patient to assure accuracy that the coordination of services such as HHC and DME’s has been completed.
• Consults with various clinical disciplines regarding specifics patient and their follow up needs.
• Identify risk management issues thru health plan guidelines and requirements and submit Incident Reports to Director.   
• Participate in monthly Staff Meetings.
• Participate in  scheduled in-service for different disciplines.
• Perform Health Risk Assessment  Program.
• Ensures compliance with Risk Management policies and incident reporting.
• Assist with Health Risk Assessment data verification.

Requirements:

• High School Diploma or GED is required.
• 1 + years Healthcare or insurance benefits is required.
• 6+ months experience in an office setting using the telephone and computer as the primary instruments to perform the job is required.
• 6+ months experience in clerical or administrative role is required
• Medicare is required.
• 1 + years Medical Terminology/Coding (ICD-9 and CPT) is required
• Bilingual (English /Spanish) is required.
• Ability to work second shift 2:00pm - 11:00pm is required.

Assets:

• Call Center with high volume is preferred
• Hospital, physician, or medical clinical is preferred
• Experience in Managed Care or Home Health care preferred.
• Medicaid is preferred.
• Knowledge or overview of Utilization Review functions is preferred.
• Ability to interpret medical records and establish rapport with clinical and administrative staff, as well as providers is a plus.