Clinical Appeals Nurse, Home Infusion - Office Based - Lenexa, KS

Careers with OptumRx. We’re one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you’ll fill far more than prescriptions. As a member of one of our pharmacy teams, you’re empowered to be your best and do whatever it takes to help each customer. You’ll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There’s no better place to help people live healthier lives while doing your life's best work.(sm)
 
Under supervision, investigates and submits complex and sensitive infusion service - related documentation to health insurance carriers on behalf of OptumRx / AxelaCare patients. Analyzes past, current and proposed treatment protocols to ensure their appropriateness and responsiveness to patient needs. Conducts clinical literature research and reviews payor coverage guidelines.  Writes clinical summaries or appeals for patients requiring complex infusible medications. Develops written patient history and infusion treatment proposals to meet specific patient health insurance needs.  May engage in dialog with Medical Directors or other clinicians at the payors to discuss patient charts or other clinical data.
 
Primary Responsibilities:

Receive patient history from patients, family members and physicians’ office
Provide assistance to the patient with obtaining facts and care history to substantiate appropriate infusion treatment
Document patient demographic data, synopsis of care history, and compose letters or e - mails to payers with proposed treatment plan in accordance with health plan requirements
Develop a consultant relationship with assigned physicians / clinics / patients to build and sustain a patient - focused approached to care
Examine work for exactness, neatness, and conformance to templates and company processes
Influence change across assigned payers
Facilitate resolution of treatment requests for assigned patients
Advocates patient viewpoints to payers on decisions directly affecting coverage - related concerns
Provide opportunities for patient involvement and input on care related issues and concerns to demonstrate commitment and responsiveness to patient needs
Participate on committees, work groups, and / or process improvement teams that improve patient outcomes and satisfaction
Reports statistical results of all efforts by presentations as needed at meetings of the management team
 

Required Qualifications:

Licensed Registered Nurse (RN) in the state of Kansas, or have the ability to obtain licensure
2+ years clinical experience as a Registered Nurse
Understanding of clinical documentation from physician offices and telephonic assessment notes of patients
Understanding of health insurance summary plan description language
Ability to clearly and effectively communicate ideas and data both verbally and in writing
Proficient in Windows - based operating software / system
Ability to work under pressure with tight deadlines
Excellent problem solving skills
Ability to develop and maintain strong clinician / client relationships
Preferred Qualifications:

Bachelor’s degree
Clinical experience with Neuro auto - immune diseases
Knowledge of specialty infusions such as IVIG and Remicade
Prior authorization, pre - certification, utilization review and / or appeals experience
Understanding of how payer reimbursements work, plus co - pays, co - insurances and deductibles
Understanding of government payment systems such as Medicare and Medicaid
Careers with AxelaCare. Discover a health services career that encourages your professional growth while delivering steadfast commitment to exceptional patient care. That's what you discover at AxelaCare. We were founded by a close group of medical professionals in Lenexa, KS to provide patient-focused, state of the art home infusion services for acute, hemophilia and Intravenous Immune Globulin (IVIg) therapies. Today we collaborate with leading doctors to develop breakthrough technologies for patient outcomes assessment; and we recently joined Optum, part of the UnitedHealth Group family of companies. It all reinforces our commitment to empowering people in the pursuit and delivery of exceptional patient care, and creating personalized career paths to discovering your life's best work.(sm)
 
 
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. 
 
 
Job Keywords: Registered Nurse, Clinical Appeals, prior authorization, pre-certification, utilization review, case manager, specialty infusion, axelacare, Lenexa, KS, Kansas
 
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