Job Description
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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start
Caring. Connecting. Growing together. At OptumHealth, you will perform within an innovative culture that's focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that's greater than you've ever imagined.
As a Stop Loss Nurse Consultant, you will develop and implement process improvements to help increase company growth. This role provides a nice change from a clinical environment and the chance to learn something new every day!
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities - Review and assess large claim notices for potential risks (approx. 25%)
- Set-up potential large dollar claimants in POWER for ongoing risk assessment and allocation of reserves
- Continue to follow these claimants on a monthly or bi-weekly basis depending on the severity and change in treatment
- Know when to set these claimants up based on clinical and cost knowledge
- Complete review of LCNs within 48 business hours of receipt
- Notify underwriter and claims auditor of potential risk when first notice received and again as risk changes
- Educate non-medical internal and external customers regarding clinical trends, treatments, possible outcomes
- Research medical conditions and disease states for appropriate treatment for specific conditions
- Utilize reputable clinical resources for research as needed such as NCCN, CDC, Predict Dx
- Assess all claimants for potential cost containment opportunities (approx. 20%)
- Collaborate with TPA, case manager, claims auditor, underwriter, vendor to discuss and place appropriate cost containment measures
- Maintain timely diary follow-up of all claimants open in POWER (10%)
- Index all documentation received
- Co-manage complex medical cases with Transplant/Dialysis coordinator
- Provide clinical claim file review for claims auditor as needed (5%)
- Perform appropriate research for each clinical claim file review request
- Provide discussion/answer questions for claims auditor as needed
- Perform experimental/investigational file reviews for Claims
- Review PYCS to assist claim auditor in setting appropriate reserves based on known or anticipated cost
- Review all documents indexed into the package for each cost estimator request (approx. 40% but during busy season—end of August to December approx. 75%)
- Perform appropriate research for each cost estimator request
- Identify all actual and potential risks for each cost estimator request
- Document clinical summary and estimate cost of care for each individual identified as at risk
- Provide re-review of additional information for updated cost estimates as needed
- Complete requests for cost estimates on new business within 24 business hours of receipt and on renewal business within 48 business hours of receipt
- Provide discussion/answer questions for underwriter as needed
- Complete Hot Claims reports as needed. This is used to track large claims and any cost containment strategies put in place
- 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 - Active and unrestricted RN license in current state of residence
- 5+ years of clinical experience
- 2+ years of experience working in an ER, ICU or Critical Care environment
- 2+ years of experience working in an insurance or managed care company, or working with a third party administrator
- 1+ year hands on Excel experience
Preferred Qualifications - Employer Stop Loss experience
- Provider Stop Loss, HMO experience
- Demonstrated ability to multitask and remain organized
- Computer proficiency, specifically solid typing skills and Internet research skills, must have a clear understanding of Microsoft Word and Excel
- 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 $71,200 to $127,200 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.
Job Tags
Minimum wage, Full time, Work experience placement, Local area,