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.
Required Qualifications
- Associate's degree in Nursing
- Unrestricted RN license required in the state of Massachusetts
- 3+ years HCBS, LTSS clinical experience in case management and utilization management
- Designated workspace and access to install secure high-speed internet via cable or DSL in home
- Reside in the state of Massachusetts
Preferred Qualifications
- Prior-Authorization experience
- Utilization Management experience
- Appeals Experience
- Medicare/Medicaid experience preferred
- Proficient with Microsoft Office programs, including Word, Excel, PowerPoint
- Excellent communications skills, including the ability to write clearly, succinctly and in a manner that appeals to a wide audience
- Excellent time management, organizational, and prioritization skills with ability to balance multiple priorities
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
The hourly pay for this role will range from $29 - $52 per hour based on full-time employment.