Clinical Pre-Service Reviewer, Occupational Therapist Location: Remote, United States Job Description: Requisition number: 2365555 Job category: Medical & Clinical Operations Primary location: Boston, MA Overtime status: Non-exempt Travel: No Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. 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 assist 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 recommend 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 Corenlius 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 recommend 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 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: - 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 *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 hourly pay for this role will range from $35.00 to $63.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable. 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.