Pre-Authorization Specialist

Pre-Authorization Specialist

Optum is seeking a Remote Pre-Authorization Specialist to join their team. This role is crucial in connecting people with the care, pharmacy benefits, data, and resources they need to live healthier lives. You will directly improve health outcomes by implementing and executing referral and authorization processes. This is a great opportunity to work with talented peers in an inclusive culture with comprehensive benefits and career development.

About the Role

As a Pre-Authorization Specialist, you will be responsible for the effective execution of Optum's referral and authorization processes. You will respond to inquiries from patients, staff, and physicians, research medical history and diagnostic tests, and coordinate prospective, concurrent, and retrospective referrals. This full-time position operates Monday through Friday, with specific business hours and potential for occasional overtime.

Primary Responsibilities

• Initiate Referral Authorizations: Maintain knowledge of health plan agreements, provide administrative support, gather information, submit requests, and track authorization status. Educate stakeholders on health plan requirements and act as a liaison between various parties.
• Review Denied Claims: Research root causes of missing authorizations/referrals, process denied claims, obtain retro-authorizations, and identify areas for improvement.
• Utilization Management Medical Review: Process referrals in EPIC, utilize medical guidelines (MCG, NCCN, etc.), review clinical records, discuss medical guidelines with insurance plans, and document accurately in the medical record.

Required Qualifications

• High School Diploma / GED or equivalent work experience.
• 1+ years of experience in healthcare, including understanding of health plan operations.
• Experience in Referrals/Pre-authorization Management/Claims billing.
• Proficient with computer and Windows PC applications, including new system learning.
• Experience with Microsoft Outlook, Word, and Teams.
• Experience with EHR/EMR systems (e.g., Epic).
• Willingness and ability to travel annually for an on-site meeting in Everett, WA.
• Ability to work full-time during specified business hours (7:00 am - 4:30 pm Mon-Thurs, 8:00 am - 12:00 pm Fri PST), with potential for overtime.
• Must reside within Washington OR Oregon.
• Must have a dedicated, private workspace with reliable high-speed internet.

Preferred Qualifications

• 1+ years of experience in Referrals/Pre-authorization Management.
• 1+ years in appeal writing and processing.
• 1+ years working knowledge of EOB, COB, Remits, and CMS 1500.
• Knowledge of organizational policies, procedures, & systems.
• Working knowledge of CPT & Diagnosis Coding, Medical Terminology, and basic Anatomy.

Telecommuting Requirements

• Reside within Washington OR Oregon.
• Ability to keep company sensitive documents secure.
• Must have a dedicated work area for privacy and security.
• Must have a UnitedHealth Group approved high-speed internet connection.
• Adherence to UnitedHealth Group's Telecommuter Policy is required.

Compensation and Benefits

The hourly pay for this role ranges from $17.98 - $32.12. In addition to salary, Optum offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution, subject to eligibility requirements.

About Optum and UnitedHealth Group

Optum, part of UnitedHealth Group, is dedicated to making health systems work better for everyone. The company is committed to equitable care, addressing health disparities, and improving health outcomes. UnitedHealth Group is an Equal Employment Opportunity employer and a drug-free workplace.

Key skills/competency

• Pre-Authorization
• Referral Management
• Health Plan Operations
• Claims Billing
• EHR/EMR Systems
• Medical Terminology
• CPT Coding
• Diagnosis Coding
• Patient Services
• Revenue Cycle Management