Talk about meaningful work. Talk about animportant role. Let's talk about your next career move. Due to our expandingbusiness, Optum, part of the UnitedHealth Group family of businesses is seekingClinical Administrative Coordinators who share our passion for helping otherslive healthier lives. As one of the world's leading health care companies,Optum is pursuing innovative new ways to operate our service centers andimprove on our ability to deliver high-quality care. As part of our clinicalsupport team, you will be a key component in customer satisfaction and have aresponsibility to make every contact informative, productive and positive forour members and providers. You'll have the opportunity to do live outreach,educating members about program benefits and services while also helping tomanage member cases. Bring your skills and talents to a role where you'll havethe opportunity to make an impact on a huge scale. Take this opportunity andbegin doing your life's best work.(sm)What makes your clinical career greater with Optum? You'll work within anincredible team culture; a clinical and business collaboration that is learningand evolving every day. And, when you contribute, you'll open doors foryourself that simply do not exist in any other organization, anywhere.Primary Responsibilities:Act as a Subject Matter Expert for other teammembersManage the intake of members or theadmission/discharge information post notification Work with hospitals, clinics, facilities andthe clinical team to manage request for services from members and/or providersManage the referrals process, processingincoming and outgoing referrals, and prior authorizations, including intake,notification and census rolesProvide appropriate triage and carecoordination notification cases for non-clinical assessment/interventionProcess notification requirements Assist the clinical staff with setting updocuments/triage cases for Clinical Coverage ReviewHandle resolution/inquiries from members and/or providers that may include: - Benefit and Eligibility information - Billing and Payment issues - Customer material requests - Physician assignments - Authorization for treatment - Explanation of Benefits (EOB) - Verifying appropriate ICD-9 and CPT coding usagePerform initial review of consumer health records and current health status (e.g., health risk scores) to identify health risk and determine next stepsReceive information from consumers about specific symptoms and questionsConduct interviews to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacyAsk open ended questions, identify significant from insignificant responses, ask about other diagnoses, probe for additional information, and redirect as necessaryEvaluate consumer data throughout the assessment process to identify inconsistencies and adherence to Evidence Based Guidelines Identify and prioritize gaps to develop plan of care to empower consumers to meet identified goalsDetermine consumer's willingness to engage in plan of care and readiness for changeDocument assessment information and enter data in appropriate systemIdentify needs and goals, determines, modifies and prioritizes strategies to support the consumer is achieving the goals and expectationsConsult with others (e.g., interdisciplinary team members) to review clinical assessment and obtain input as necessaryIdentify appropriate interventions and resources to meet gaps (e.g., psychosocial, transportation, long-term care) based on specific consumer needsReview and identify appropriate evidence based information for consumersConsult with consumer regarding possible areas for intervention and prioritiesDetermine short and long term health goalsEvaluate the consumer's understanding of health gaps and potential interventionsDiscuss benefits and risks of potential interventions with consumer to assess their willingness to change and support the plan of careTake member support and priorities into account to identify initial plan of careDocument the plan of care in appropriate systems and enter data per specified formatRefer consumers to appropriate internal and external resources as neededEngage consumer with meaningful interaction that will motivate commitment and increase level of activationIdentify possible challenges to consumer success and provide continued support for goal attainmentContact member or provider to gather information on consumer progress toward plan goalsIdentify opportunities to update the care plan based on preferences, knowledge, success, progressMaintain consumer engagement by establishing rapport, demonstrating empathy, and building a trusting relationshipCommunicate rationale for interventions that are tailored to each situation to best teach and motivate consumersPartner with primary providers or multidisciplinary team to align or integrate goals to plan of careDetermine consumer's level of health literacy and adjust approach or explanations to meet consumer needsProvide approved health information resources to consumers in a secure fashion (e.g., web links, e-mails)Document information using appropriate grammar, spelling, and punctuation, and ensure all critical information is included per documentation guidelinesReassess plan of care at appropriate intervals based on initial objectives, significant change of condition, or achievement of goalsConduct follow up calls as indicated to reevaluate plan of careDetermine whether consumer can demonstrate goal attainmentEvaluate effectiveness of specific interventions to determine whether desired outcomes are achievedRevise plans of care or close cases based on consumer success toward goalsDocument goal attainment (e.g., proof points, completion of intervention to obtain goal, caller understanding of action plan) and enter data in appropriate systemsDemonstrate knowledge of computer functionality and software applications (e.g., navigating systems, troubleshooting, electronic charting, accessing intranet and record management databases)Demonstrate knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, commercial) or regulatory bodies (e.g., HIPAA, URAC, ISO, Milliman, NCQA)Demonstrate understanding of relevant health care benefit plans (e.g., conservation of benefits)Demonstrate knowledge of applicable area of clinical specializationUtilize resources to enhance professional practice and development based on learning gaps or new informationDemonstrate understanding of business implications of clinical decisionsIdentify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as neededUtilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business resultsIdentify and implement innovative approaches to the practice, in order to achieve or enhance quality outcomes and financial performanceUse appropriate business metrics (e.g. member/FTE, length of stay, readmission rates, STAR ratings, member engagement rates) and applicable processes/tools (e.g. cost benefit analysis, return on investment, performance, staffing calculator) to optimize decisions and clinical outcomesPrioritize work based on business algorithms and established work processes, or in their absence, identify business priorities and build consensus to triage and deliver work (e.g. assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up.)Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state.)
Our mission is to help people live healthier lives and to help make the health system work better for everyone.
- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities.
- We work with health care professionals and other key partners to expand access to quality health care so people get the care t...hey need at an affordable price.
- We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.