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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)
Supervisor who coordinates, oversees and is accountable for the daily activities of business support, technical or production team or unit. The team that the supervisor will handle claims and are responsible for providing expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims.
Responsibilities include performing reconsideration retrospective review of inpatient cases applying MCG/IQ criteria for approval/denial and sending to MD for final review
Generally, reviews medical claims for medical necessity, but not limited to the following:
- Assess and interprets customer needs, requirements and medical records,
- Identifies solutions to non-standard requests and problems,
- Solves moderate to complex problems and do analysis with it, works with minimal guidance, translates clinical concepts into practice, provides explanations and information for difficult issues
- Owns output at task level
- Work is generally limited to own function
- Sets priorities for the team to ensure task completion
- Coordinates work activities with other supervisors
- Develops plans to meet short-term objectives
- Identifies and resolves operational problems using defined processes, expertise and judgment
- Decisions are guided by policies, procedures and business plan
- Product, service or process decisions are most likely to impact individual employees and/or customers (internal or external)
- Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so
Positions in this function require various nurse licensure and may require certification based on role and grade level. Licensure includes RN and LPN/LVN , depending on grade level, with current unrestricted licensure in applicable state. Roles are responsible for retrospective review of medical claims and application of medical and reimbursement policies. *Employees in jobs labeled with ‘SCA’ must support a government Service Contract Act (SCA) agreement.
- Undergraduate degree or equivalent experience
- Active mainland USRN License with minimum of 2 years of experience in ER/Med-Surg/Critical Care Units/OR
Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.
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.
Diversity creates a healthier atmosphere: Optum 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.
Optum is a drug-free workplace. © 2022 Optum Global Solutions (Philippines) Inc. All rights reserved.