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SalaryOpportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff, and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.
Under the supervision of the Medical Claims Review (MCR) Supervisor, this position is responsible for processing Utilization Management (UM) Inventory. MCR Coordinator is responsible for handling customer service or provider calls as needed. Coordinates UM processes with WellMed Medical Directors, UM Nurses, hospitals, physicians and other various departments. MCR Coordinator is responsible for providing clerical support to WellMed clinical staff for their medical necessity review process. MCR Coordinator is expected to maintain production and quality standards.
If you reside in San Antonio, TX, you will enjoy the flexibility of a hybrid-remote role as you take on some tough challenges. Will be required to report to office location and have the option for future remote work pending business needs.
Primary Responsibilities:
- Research and resolve UM inventory accordingly to meet productivity and quality standards to include:
- Claims reports with reconciliation needs
- Information received through Right Fax
- Information received through email
- Or any other methods of receipt (phone calls, etc.)
- Coordinates initial screening for UM claim reviews through claim queue
- Prepares administrative files for Medical Directors, UM Nurses and Case Managers
- Contacts provider offices to obtain clinical information for medical review by a clinician to meet Center for Medicare and Medicaid Services (CMS), state and health plan guidelines/regulations
- Documents and follows-up on all assigned inventory, utilizing on-line systems and procedures, according to established guidelines
- Maintains knowledge of various health plan partner benefits, networks, CMS regulations and health plan partner policies
- Utilize experience and judgement to plan, accomplish goals and effectively resolve each assigned task
- Receives and responds to telephone calls through the UM Phone Queue, as needed
- Performs all other related duties as assigned
Required Qualifications:
- High School Diploma / GED (or higher)
- 2+ years of managed care experience in Prior Authorization or Claim Review
- Medical Terminology, ICD-9/ICD-10, and CPT knowledge
- Proficient with Medicare processing guidelines, working knowledge of medical contracts
- Proficiency with Microsoft Office applications, i.e., Excel, Access
- Reside in San Antonio, TX or proximity
Physical & Mental Requirements:
- Ability to stand for extended periods of time
- Ability to properly drive and operate a company vehicle
- All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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.
