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Job Details

UnitedHealth Group

Utilization Management Specialist I - Hybrid, The Everett Clinic - Seattle, WA


Laboratory Management


Everett, Washington, United States

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

The Business Services department is seeking an Utilization Management Specialist I to join their team full time working out of Seattle, WA. Remote option available (must be willing to go to Seattle location if/when network issues arise). Must be located in Washington State.

The Utilization Management Specialist I implements, maintains and executes procedures and processes by which TEC performs its referral and authorization process. This position responds to inquiries from patients, staff and physicians pertaining to managed care benefits and referral authorization status. In addition, this position sends out confirming copies of referrals, authorizations or denial letters as required by health plan guidelines. The position also researches medical history and diagnostic tests when requested, to assist in review, processing, and coordination of prospective, concurrent and retrospective referrals.

Primary Responsibilities:

  • Consistently exhibits behavior and communication skills that demonstrate our company’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
  • Uses, protects, and discloses our patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
  • Researches, collects, and analyzes primary and secondary data sources and reports trends to support department goals.
  • Designs and evaluates database systems to support department needs.
  • Develops and maintains organized documentation for efficient department operations.
  • Supports performance improvement duties for the department.
  • Recommends strategies in relation to report building and data capture for internal customers.
  • Performs additional duties as assigned.
  • Develop metrics and analytics to assess quality of care delivery and patient outcomes
  • Communicate findings with key stakeholders
  • Acquires and maintain a working knowledge of Optum contracted health plans agreements and related insurance products
  • Provides administrative and enrollment support for team to meet Company goals
  • Gathers information from relevant sources for processing referrals and authorization requests
  • Submits authorization & referral requests to health plan via avenue of insurance requirement. Including but not limited to website, phone, & fax
  • Track authorization status inquires for timely response
  • Maintains strong understanding of and educate our physicians, clinical teammates, patients and families regarding contracted health plans requirements related to Utilization Management and authorizations.
  • Acts as a liaison between providers, teammates, outside vendors, health plans, community services and patients to support Utilization Management process and requirements
  • Reviews benefit language and medical records to assist in completion of requested services, to meet health plan requirements
  • Documents patient information in the electronic health record following standard work guidelines
  • Coordinates with Clinical teammates and health plans to identify patients with Utilization Management needs
  • Provides member services to all patient group
  • Answers referral and authorization inquiries from health plans, our clinical areas, patients and outside Optum Physician office/facilities
  • Assists in the development and implementation of job specific policy and procedures
  • Assists in the collection of information for member and/or provider appeals of denied requests
  • Identifies areas for potential improvement of patient satisfaction
  • Researches root causes of missing authorization/referral
  • Processes no authorization, no referral denied claims based on Insurance plans billing guidelines
  • Obtains retro authorizations, appeals denied claims, or writes off charges based on Optum charge write-off guidelines
  • Provides feedback and follow up to clinical areas and appropriate parties
  • Assists in the development and implementation of job specific policies and procedures to reduce no authorization no referral denied claims to increase revenue
  • Initiates improvement in authorization timeliness, accuracy and reimbursement.

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:

  • High school, GED, or equivalent experience
  • 2+ years of work experience in healthcare
  • Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifications:

  • Knowledge of EPIC
  • Knowledge of Microsoft Word and Excel
  • Knowledge of ICD-10 and CPT coding
  • Experience in Utilization Management
  • Certification from WA State Department of Health as a Medical Assistant-Certified Certified Professional Coder (CPC) or equivalent

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

For more information on our Internal Job Posting Policy, click here.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Colorado, Connecticut or Nevada Residents Only: The hourly range for Colorado residents is $16.00 to $26.88. The hourly range for Connecticut/Nevada residents is $16.83 to $29.66. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.