Our Ability Jobs

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere.

As a team member of our naviHealth product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home.

As an Appeals and Denials team member, you will help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home.

We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

Why naviHealth?

At naviHealth, our mission is to work with extraordinarily talented people who are committed to making a positive and powerful impact on society by transforming health care. naviHealth is the result of almost two decades of dedicated visionary leaders and innovative organizations challenging the status quo for care transition solutions. We do health care differently and we are changing health care one patient at a time. Moreover, have a genuine passion and energy to grow within an aggressive and fun environment, using the latest technologies in alignment with the company’s technical vision and strategy.

This is a full-time position with the following Monday through Friday, midday to evening schedules available:

10am – 7pm Central, 11am – 8pm Central, 12pm – 9pm Central, and 1pm – 10pm Central

We offer a shift differential for working a minimum of two hours after 6pm in the local time zone. The position includes 4-6 weeks of paid training which may be at an earlier schedule than those listed above. This position also requires working four holidays per year on a rotating basis. Employees will receive holiday pay. Opportunities for overtime may be offered based on business needs.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Ensure timely processing of all denial-related and member-oriented written communications. Ensure all denial information is processed according to protocol and documentation is timely and meets all Federal and State requirements

• Ensure second-level reviews have been performed and documented. May confer with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICCs), Skilled Inpatient Care Coordinators (SICCs), Pre-service Coordinators (PSCs) and facility personnel to ensure denial information is processed timely and appropriately

• Serve as a liaison by communicating with internal and external customers including health plans, providers, members, quality organizations, and other colleagues

• Document and communicate appeal and denial information via fax, email, or established portal access, including appeal and denial letters, NOMNC letters, AOR forms, and clinical information

• Act as a point person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their teams

• Serve as a liaison for requests for information from QIO or health plan staff

• Own assigned appeal requests or determination notifications that are received via fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management

• Complete appeal and denial processes in accordance with CMS and Optum guidelines and compliance policies

• Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability (including proper grammar, spelling, punctuation, etc.), as well as the. ability to follow grade-level requirements (including, but not limited to DENC letter, IDN letter, Exhaustion of Benefits letter, Administrative Denial letter, Provider Denial letter)

• Review NOMNC for validity before processing appeal requests

• Send reviews to Medical Director for rescinding NOMNC when necessary

• Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed

• Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed

• Follow all established facility policies and procedures

• Assist with completing pre-service authorization requests to assist the pre-service team as needed

• Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs

• Perform other duties and responsibilities as required, assigned, or requested

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, unrestricted registered clinical license in state of hire – Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist

• 3+ years of clinical experience as a Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist

• Demonstrated excellent documentation skills

• Demonstrated exceptional verbal and written interpersonal and communication skills

• Proficient with Windows and Microsoft Office Suite

• Ability to work one of the following Monday – Friday schedules: 10am – 7pm Central, 11am – 8pm Central, 12pm – 9pm Central, or 1pm – 10pm Central

• Ability to work four holidays per year on a rotating basis

• Dedicated, distraction-free workspace and the ability to install high speed internet via DSL/Cable Broadband/Fiber at home

Preferred Qualifications:

• Compact licensure or multiple state licensures

• Managed care experience

• Case management experience

• Experience processing appeals and/or denials

• Experience with utilization management, utilization review, or insurance authorizations

• Experience determining levels of care

• ICD-10 experience

• InterQual experience

• Demonstrated understanding of CMS regulations

• Demonstrated understanding of the denial process

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, or Washington, D.C. Residents Only: The hourly range for this role is $33.75 to $66.25 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with al minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.

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.