Requisition number: 2361427
Job category: Medical & Clinical Operations
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
The Clinical Consultant is responsible for reviewing large claim notices to identify potential risks, setting up and monitoring claimants in POWER, and notifying relevant stakeholders as risk levels change. The role also involves educating internal and external customers about clinical trends, researching disease states using reputable resources, and assessing opportunities for cost containment.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
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Review and assess large claim notices for potential risks. (approx. 25%)
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Set-up potential large dollar claimants in POWER for ongoing risk assessment and allocation of reserves
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Continue to follow these claimants on a monthly or bi-weekly basis depending on the severity and change in treatment
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Know when to set these claimants up based on clinical and cost knowledge
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Complete review of LCNs within 48 business hours of receipt
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Notify underwriter and claims auditor of potential risk when first notice received and again as risk changes
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Educate non-medical internal and external customers regarding clinical trends, treatments, possible outcomes
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Research medical conditions and disease states for appropriate treatment for specific conditions
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Utilize reputable clinical resources for research as needed such as NCCN, CDC, Predict Dx
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Assess all claimants for potential cost containment opportunities. (approx. 20%)
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Collaborate with TPA, case manager, claims auditor, underwriter, vendor to discuss and place appropriate cost containment measures
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Maintain timely diary follow-up of all claimants open in POWER. (10%)
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Index all documentation received
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Co-manage complex medical cases with Transplant/Dialysis coordinator
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Provide clinical claim file review for claims auditor as needed. (5%)
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Perform appropriate research for each clinical claim file review request
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Provide discussion/answer questions for claims auditor as needed
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Perform experimental/investigational file reviews for Claims
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Review PYCS to assist claim auditor in setting appropriate reserves based on known or anticipated cost
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Reviewed all documents indexed into the package for each cost estimator request (approx. 40% but during busy season-end of August to December approx. 75%)
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Perform appropriate research for each cost estimator request
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Identify all actual and potential risks for each cost estimator request
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Document clinical summary and estimate cost of care for each individual identified as at risk
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Provide re-review of additional information for updated cost estimates as needed
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Complete requests for cost estimates on new business within 24 business hours of receipt and on renewal business within 48 business hours of receipt
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Provide discussion/answer questions for underwriter as needed
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Complete Hot Claims reports as needed. This is used to track large claims and any cost containment strategies put in place
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Attend monthly Account Management/Sales calls
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
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Current and unrestricted RN license in the state of residence
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5+ years of clinical experience
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2+ years of ER, critical care or oncology experience
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2+ years of experience working in an insurance or managed care company, or working with a third-party administrator
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Proficient in Microsoft Excel
Preferred Qualifications:
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Employer Stop Loss experience
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Computer proficiency, specifically solid typing skills and Internet research skills
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Demonstrated ability to multitask and remain organized
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
