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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale.Join us to start Caring. Connecting. Growing together.
Reporting to and working under the general direction of the Supervisor(s) and Manager of the department, the Specialty Navigator Optum Massachusetts reviews complex referral requests and evaluates and assigns appropriate specialist for the patient. Works with patients and providers to understand services being requested. Interviews patients as needed to obtain full understanding of what information is being requested. Works closely with Specialty Nurses to ensure clinical handoffs are safe and appropriate. Coordinates care both within Reliant and Atrius Health and with external partners.
Schedule: Monday - Friday; will be working a typical day shift between the hours of 8am - 6pm.
Location: This role is Remote in Worcester, MA. Will be required to come onsite when needed at manager's discretion.
If you are located within a commutable distance to our Reliant office at 385 Grove St. Worcester, MA, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities
- Reviews referral information from clinicians for pertinent information regarding tests, consultations, and procedures. Verifies demographics and insurance information. Work is highly complex and detail oriented, involving frequent contact with a range of internal and external contacts as well as the need to understand terms and processes of multiple payers.
- Reviews each external referral for opportunity to convert to internal referral and reviews options with patients. Redirects patients with managed care products appropriately ensuring clinical handoff is safe using expertise of specialty nurses. Ensures adequate information is obtained and relayed when care is moved.
- Explains insurance benefits and options to patients. Explains denials to patients. Keeps patient informed of status of all referrals (approved and denied). Notifies patients of scheduled appointments and confirms appointment by mail including confirmed location and map of destination. Informs patient of any preparation that must be completed prior to the appointment. Contacts patient if insurance coverage issues arise during the referral process so that patient can work directly with the insurance company.
- Promotes the Reliant and Atrius Health System of Care by highlighting internal providers and their expertise.
- As needed, places orders to start the referral process for the PCP on behalf of patients who have booked appointments and call for the referral. Researches the visit notes to determine if a referral was intended as well as processing referrals for follow-up or annual visits that require a referral.
- Schedules patients for tests, consultations, services and procedures with other departments, local private offices, and/or outside vendors/providers.
- /Answers phone calls, faxed requests and other inquires relating to referrals and communicates with the physicians and clinicians to acquire authorization or to inform them of patient issues or clinical paperwork needed.
- Research questions/concerns from patients regarding bills and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process. Refers patients to appropriate staff (e.g., patient account representatives) for billing issues related to insurance benefits and services covered under the benefits plan.
- Works in collaboration with the person designated as the Practice's Benefits Coordinator to maintain cost control, ensure that services provided are within benefit plan guidelines, and that necessary policies and procedures are followed when dealing with non-preferred providers/vendors. May coordinate second opinion requests.
- Works with supervisors to ensure patients are receiving timely responses and detailed answers to their complex questions.
- Research questions/concerns from patients regarding billing and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process.
- Receives escalated issues and stat same day calls; determine appropriate action and/or works with clinical team for decision.
- Effectively deescalates issues with upset patients and practices. Uses advanced listening techniques to understand the issue and give patients options as they are available. Escalates to supervisors only as needed.
- Participates in problem solving activities, focusing on productivity and quality. Works with supervisors to ensure continuous improvement of the department.
- If needed, contacts appropriate parties to obtain referral authorizations and verify coverage (e.g., the Authorization Services Unit (ASU), National Imaging Associates (NIA) or individual insurance companies). Certain departments may also need to contact additional outside agencies for approval (e.g., American Imaging Management or Med Solutions).
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions 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/GED
- 1+ years of administrative experience in a medical or healthcare setting
Preferred Qualifications
- EMR experience (EPIC preferred)
Skills
- Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.
- Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
- Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.
- Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.
- Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.
- Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.
- Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.
- Teamwork: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members
*All Telecommuters 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 $18.00 to $32.00 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.
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