Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. If you reside near Boston, MA, you will enjoy the flexibility to telecommute* as you take on some tough challenges. Primary Responsibilities: • Determine whether the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) • Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) • Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation to support PA requests • Represent MassHealth at appeal hearings • Defend MassHealth prior authorization decisions by utilizing program specific regulations, medical necessity guidelines, standards of care and best practices • Represents the MA MLTSS program in a positive, solution-focused manner that embodies our corporate values: Integrity, Compassion, Relationships, Innovation and Performance • Determine the appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination • Identify solutions to non-standard requests and problems • Participate in regular meetings to collaborate with supporting leadership and team to ensure operational efficiency • Assures performance adheres with established quality standards, evidenced based practice guidelines and departmental benchmarks and workflows • Act as a resource for others; provide explanations and information on difficult issues • Minimum 10% travel within the state of MA You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Optum Home & Community Care is part of UnitedHealth Group and provides telephonic case management services to help members navigate the health care system and access support services. As an RN Case Manager, you would assess members' health status, identify gaps in treatment plans, establish care goals, coordinate with multidisciplinary teams including mental health clinicians, provide patient education and coaching, make referrals to community resources, and facilitate transitions between care settings—primarily through phone calls in a high-volume customer service environment.
