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- Hartford, CT
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Sr. Clinical Analyst RN (Stop Loss) – Telecommute!
UnitedHealth Group • Hartford, CT
Posted 4 days ago
- Review and assess large claim notices for potential risks. (approx. 25%)
- Set-up potential large dollar claimants in POWER for ongoing risk assessment and allocation of reserves
- Continue to follow these claimants on a monthly or bi-weekly basis depending on the severity and change in treatment
- Know when to set these claimants up based on clinical and cost knowledge
- Complete review of LCNs within 48 business hours of receipt
- Notify underwriter and claims auditor of potential risk when first notice received and again as risk changes
- Educate non-medical internal and external customers regarding clinical trends, treatments, possible outcomes
- Research medical conditions and disease states for appropriate treatment for specific conditions
- Utilize reputable clinical resources for research as needed such as NCCN, CDC, Predict Dx
- Assess all claimants for potential cost containment opportunities. (approx. 20%)
- Collaborate with TPA, case manager, claims auditor, underwriter, vendor to discuss and place appropriate cost containment measures.
- Maintain timely diary follow-up of all claimants open in POWER. (10%)
- Index all documentation received
- Co-manage complex medical cases with Transplant/Dialysis coordinator
- Provide clinical claim file review for claims auditor as needed. (5%)
- Perform appropriate research for each clinical claim file review request
- Provide discussion/answer questions for claims auditor as needed
- Perform experimental/investigational file reviews for Claims
- Review PYCS to assist claim auditor in setting appropriate reserves based on known or anticipated cost
- Review all documents indexed into the package for each cost estimator request. (approx. 40% but during busy season—end of August to December approx. 75%)
- Perform appropriate research for each cost estimator request
- Identify all actual and potential risks for each cost estimator request
- Document clinical summary and estimate cost of care for each individual identified as at risk
- Provide re-review of additional information for updated cost estimates as needed
- Complete requests for cost estimates on new business within 24 business hours of receipt and on renewal business within 48 business hours of receipt
- Provide discussion/answer questions for underwriter as needed
- Complete Hot Claims reports as needed. This is used to track large claims and any cost containment strategies put in place.
- Attend monthly Account Management/Sales calls
- 5+ years of clinical experience
- Active and unrestricted RN license in current state of residence
- Computer proficiency, specifically strong typing skills and Internet research skills, must have a clear understanding of Microsoft Word and Excel
- Must be able to multitask and remain organized
- Bachelor’s degree
Experience working in an ER, ICU or Critical Care environment
Employer Stop Loss experience
Provider Stop Loss, HMO experience
Experience working in an insurance or managed care company, or working with a third party administrator
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy
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.