Analyst Preauthor - Worcester, MA

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

This position is full time. Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 4:30 pm EST. It may be necessary, given the business need, to work occasional overtime. Our office is located at 100 Front Street, Worcester, MA 01606.

We offer 4 weeks of on-the-job training. The hours of the training will be aligned with your schedule.

If you are within commutable distance to the office at 100 Front Street, Worcester, MA 01606, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.

Primary Responsibilities:

• Processes authorizations, redirections and denials for the organization, screens for member eligibility, retrieve clinical notes from external providers to complete our electronic medical record, and accurately enters information into the computer system. Processes authorizations, redirections, and denials per specific payor's guidelines. Schedule appointments for outgoing orders for primary care. Schedule internal orders for designated in-house specialty and high end
• imaging as part of an ongoing project to improve ability to manage and provide timely services for all patients. Staff are expected and measured on how they successful they are at redirecting orders that are placed for outside services.
• Approves, redirects, and denies routine Fallon Health, Tufts Commercial, Tufts Medicare Preferred, Blue Cross Blue Shield, Harvard Pilgrim requests by applying each physician determined protocols, policies and procedures; requests not meeting protocol parameters are prepared for physician review. Ensures that all pertinent information accompanies requests for further review; pending case to each payor's pre-authorization department or RMG Medical Director, according to the insurance plan.
• Knowledge of all insurances including HMO and PPO and advantage plans.
• Responsible for knowing the referral circles and outside specialist that Reliant has preferred and collaborative relationships with.
• Performs data entry and research on all referral requests to include inpatient surgeries, same day surgeries, specialist and PCP referrals, care management, SNF, VNA, Medicare part B services, and track inpatient admissions using payor reports.
• Works closely with appropriate clinic and payor contacts to complete the referral process.
• Monitor and research Tufts Medicare Preferred electronic claim report to determine if claims should be paid or not, work closely with the Medical Director to help facilitate with further decision making when necessary.
• Communicates with internal and external providers, staff, patients and payor representatives to facilitate the pre-authorization, redirection, or denial process. Provides recommendations to PCPs whether to approve, redirect, or deny patients based on a detailed research.
• Works in conjunction with the Provider Relations Representatives or others to conduct orientations, updates and educational sessions for providers and staff, as requested.
• Gathers all pertinent information for each referral to determine appropriateness, accuracy, contractual status, codes and to follow through to fruition (approval, redirection, and denial).Serves as a resource for the organization's providers, staff, and patients.
• Advanced training in order to deal with difficult conversations with patients and parents when services for outside services are not approved.
• Has a clear understanding and complies with risk-based contracts as this position is directly related to the financial health of the organization.
• Complies with health and safety requirements and with regulatory agencies such as DPH, etc. Strictly observes the RMG policy and procedure regarding confidentiality.
• Complies with established departmental policies, procedures, and objectives.
• Enhances professional growth and development through educational programs, seminars, etc.
• Attends a variety of meetings, conferences, and seminars as required or directed.
• Performs other similar and related duties as required or directed.
• Processes authorizations, redirections and denials for the organization members using established protocols, policies and procedures and related duties.

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:

• High school diploma / GED
• 18 years or older
• Ability to travel up to 100% of the time
• Ability to work full time. Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 4:30pm EST. It may be necessary, given the business need, to work occasional overtime.

Preferred Qualifications:

• Microsoft Office Suites
• 1+ years experience in healthcare
• Proficient with data manipulation including the ability to develop spreadsheets, build data tables and extract data
• Proficiency with electronic medical record systems
• Knowledge and understanding of medical terminology

Telecommuting Requirements:

• Reside within commutable distance to the office at 100 Front Street, Worcester, MA 01606.
• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

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

The hourly range for this role is $16.88 to $33.22 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all 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.

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.