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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come makes an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. The Clinical Appeals RN is responsible for attending appeal hearings, defending MassHealth prior authorization decisions, and performing pre-service/prior authorization clinical coverage review of services. Works closely with managers and peers. If you currently reside in the state of Massachusetts, you'll enjoy the flexibility to telecommute* as you take on some tough challenges. Primary Responsibilities: • 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 What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include: • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays • Medical Plan options along with participation in a Health Spending Account or a Health Saving account • Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage • 401(k) Savings Plan, Employee Stock Purchase Plan • Education Reimbursement • Employee Discounts • Employee Assistance Program • Employee Referral Bonus Program • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.) 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.
