UnitedHealth Group is a healthcare and well-being company that’s dedicated to improving the health outcomes of millions around the world. We are comprised of
Clinical Pre-Service Reviewer
Location
United States
Posted
10 days ago
Salary
$35 - $63 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Clinical Pre-Service Reviewer
UnitedHealth Group
Role Description The Clinical Preservice/Clinical Appeals Reviewer is responsible for performing MassHealth LTSS pre-service clinical coverage reviews and determinations and clinically appropriate appeal hearing representation. The Preservice Reviewer/ Clinical Appeals is responsible for attending appeal hearings, defending MassHealth LTSS prior authorization determinations. This position collaborates closely with managers and peers. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Assesses the appropriateness of services when adjudicating prior authorizations based on submitted documentation, benefit plan, MassHealth policies and medical necessity guidelines, program requirements, and standards of care. - Identifies solutions to non-standard requests and problems. - Participates in regular meetings with leadership and team members to support collaboration and ensure operational efficiency and team alignment. - Maintains performance in accordance with established quality standards, evidence-based guidelines, departmental benchmarks, and operational workflows. - Adjudicates prior authorizations in a timely manner, ensuring completion ahead of Cornelius due dates to ensure compliance with the Interoperability Rule. - Promotes consistency and accuracy in clinical decision-making by applying medical necessity guidelines and program standards across cases and programs. - Engages, coordinates, and provides education to LTSS providers on prior authorization requirements and medical necessity guidelines to support clinical decision making. - Provides clinical mentorship and guidance to support junior reviewer development. - Acts as an SME for specific service lines or programs, providing specialized expertise. - Supports cross-functional programs and workstream initiatives. - Adheres to their approved assigned schedule and participates in overtime coverage as required by program needs. - Responds to and assists with support of inquiries and escalations. - Effectively manages and prioritizes workload to meet quality and productivity goals. - Performs additional duties and provides coverage assigned by management. Clinical & Regulatory Responsibilities - Maintains compliance with MassHealth clinical guidelines, regulatory requirements (CMS and applicable state and federal regulations), and program policies. - Works with internal stakeholders (e.g., Medical Directors, Team Leads, Program Managers) to support the clinical coverage review process and elevates complex or high-risk cases to clinical leadership. - Identifies and reports on utilization trends, including potential overuse or underuse of services. - Supports audit, regulatory, and accreditation activities to maintain compliance and program integrity. - Prepares and presents cases for discussion during weekly clinical case rounds. Appeals Responsibilities - Ensures the appeals process is executed in compliance with regulatory and business unit standards, including scheduling appeals for designated PA appeals staff. - Acts as a liaison between the OLTSS and the BOH, fostering collaboration and effective communication. - Attends BOH proceedings for high-profile or complex appeal cases as needed. - Coordinates appeals activities with the applicable LTSS Program Manager. - Provides support for prehearing conferences through planning and collaboration. - Oversees quality assurance for the Appeals team, ensuring consistency and adherence to standards. - Analyzes trends within appeals and recommends policy enhancements in response to identified patterns impacting PA appeals. Documentation & Quality Assurance - Maintains clear, accurate, and defensible documentation in all prior authorization determinations and corresponding decision letters in accordance with MassHealth guidelines as well as state regulations and federal regulations. - Participates in internal and external quality audits as needed. - Drives improvement in individual quality performance and productivity metrics through ongoing monitoring and analysis. - Ensures prior authorizations are adjudicated ahead of the Cornelius due date to remain in compliance with the CMS Interoperability Rule. - Maintains a PA audit score of at least 90%. - Demonstrates proficiency by earning a minimum score of 75% on the IRR Assessment. - Performs all assigned duties in compliance with SLA and contractual requirements. Communication & Provider Collaboration - Communicates determinations clearly and professionally. - Engages in provider outreach as needed to support prior authorization determinations. - Educates providers on prior authorization and medical necessity criteria. - Collaborates with PAUM programs and MALTSS workstreams to support program objectives as appropriate. Operational Efficiency & Process Improvement - Identifies workflow inefficiencies and recommends process improvements. - Participates in process improvement projects, including automation or system enhancements. - Supports onboarding and training of new staff as needed. - Demonstrates proficiency in clinical systems and documentation tools. - Independently resolves moderately complex issues with minimal supervision. Professional Development - Maintains current clinical knowledge through ongoing continuing education, training, and professional development. - Keeps up to date with program requirements, regulatory changes, and evolving clinical guidelines. - Stays informed on industry best practices and internal organizational processes. - Monitors updates to MassHealth policies, clinical guidelines, and authorization requirements to ensure compliance. - Participates in competency assessments and completes all required ongoing training. Qualifications - Ability to maintain current professional licensure in accordance with contractual requirements, ensuring alignment with the qualifications necessary to effectively perform assigned job duties. - Demonstrated solid written and verbal communication skills, with the ability to build relationships and collaborate effectively. - Ability to work independently and as part of a team. Requirements - *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase. - 401k contribution (all benefits are subject to eligibility requirements). - Hourly pay for this role will range from $35.00 to $63.00 per hour based on full-time employment.
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