Job Pitch

WHAT WE OFFER

• Market Total Rewards Package
• Temporary work from Home / Laptop Provided
• Retirement Plan
• Medical Plan (HMO) from Day 1 of employment
• Dental, Medical, and Optical Reimbursements
• Life and Disability Insurance
• Paid Time-Off Benefits
• Sick Leave Conversion
• Tuition Fee Reimbursement
• Employee Assistance Program (EAP)
• Annual Performance Based Merit Increases
• Employee Recognition
• Training and Staff Development
• Employee Referral Program
• Employee Volunteerism Opportunity
• All Mandatory Statutory Benefits

WHO WE ARE

• Optum is the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare.
• UnitedHealth Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone.
• We’re a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center.
• As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world.
• We’re a diverse team with operations across North America, South America, Europe, Asia Pacific and the Middle East. This includes our over 25,000 employees in the Philippines.
• Elevate your career with a leading health care company while improving lives.

Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that’s dedicated to Caring. Connecting. Growing together

Job Description

*Pooling candidates in preparation for 2025 classes

ROLE AND RESPONSIBILITIES

• Function is responsible for performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
• Conduct Non-Clinical Research to Support Determinations. Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan)
• Review Existing Clinical Documentation. Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
• Make Final Determinations Based on Clinical and Departmental Guidelines. Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation)
• Achieve and Maintain Established Productivity and Quality Goals. Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations.

Your role is critical in allowing our members, families, facilities and health professionals to have greater confidence in the exceptional care we provide. And for you, an everyday opportunity to do your life’s best work.SM.

JOB QUALIFICATIONS

• Valid and unrestricted USRN license and PHRN License required
• Must have a minimum of 2 years hospital (bedside)  experience
• Preferably with a minimum of 2 years BPO experience related to Utilization Management or Case Management
• Clinical competence in understanding 

Qualification Required

• College Graduate