For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm) ***This is a MA telecommuter position, which requires travel to participate in board hearings in Massachusetts - 5 board offices in Boston area*** Primary Responsibilities: Responsible for performing prior authorization review of services that require notification, using applicable benefit plan documents, evidence - based medical policy and state specific recognized clinical guidelines and criteria Determines medical appropriateness of provider services following evaluation of medical guidelines and benefit determination Interacts with providers to obtain clinical information to support prior authorization determinations and provide support for their questions Evaluate applicability of community resources / government programs / LTSS provider services to member needs Navigate relevant computer systems to identify internal and external resources Perform / support clinical appeals (e.g., notes, previous reviews, obtain rationales); including onsite representation during the Board of Hearings
Required Qualifications:Active, unrestricted PT license in the state of MA 2+ years' of PT clinical experience2+ years hands-on work with PA Ability to collaborate with stakeholders Proficient in Microsoft Word and Outlook Ability to effectively present clear and concise Prior Authorization decision making rationalePreferred Qualifications: Experience working with individuals receiving LTSS services preferred Utilization Management experience highly preferredChart Review Ability to interpret benefits and /or apply clinical / LTSS guidelines Processing member appeals experience Case Management experience Certified Case Manager (CCM) Medicaid Experience Experience working with the LTSS populationManaged Care Experience Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: case manager, UM, UR, PA, prior authorization, pre authorization, utilization management, Utilization review, chart review, quality review, Milliman, CCM, LTSS, long term care, managed care, Medicaid, Waltham, Cambridge, Avon, Needham and Wakefield, MA, Massachusetts, physical therapy, physical therapist, PT, telecommute, telecommuter, telecommuting
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.