Specialty Navigator II

Join Our Team at Optum

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Reporting to and working under the general direction of the Supervisor(s) and Manager of the department, reviews complex referral requests and evaluates and assigns appropriate specialists for the patient. Works with patients and providers to understand services being requested. Interviews patients as needed to obtain full understanding of what information is being requested. Works closely with Specialty Nurses to ensure clinical handoffs are safe and appropriate. Coordinates care both within Atrius Health and with external partners.

Schedule: Monday - Friday, 8:30am - 5pm.

Location: 1177 Providence Hwy. Norwood, MA 02062

This is a office-based role, office-based schedule to be determined by manager upon hire.

If you are located within a commutable distance to our Norwood, MA office, you will have the flexibility to work a office-based* schedule as you take on some tough challenges.

Primary Responsibilities:

• Reviews referral information from clinicians for pertinent information regarding tests, consultations, and procedures. Verifies demographics and insurance information. Work is highly complex and detail oriented, involving frequent contact with a range of internal and external contacts as well as the need to understand terms and processes of multiple payers
• Reviews referral information from work queue for pertinent information regarding referral requests
• Conduct detailed reviews of specialty referral requests for opportunity to convert to internal referral in collaboration with clinical team members, ensuring alignment with organizational referral guidelines
• Explains insurance benefits and options to patients. Explains denials to patients. Keeps patient informed of status of all referrals (approved and denied). Notifies patients of scheduled appointments and confirms appointment by mail including confirmed location and map of destination. Informs patient of any preparation that must be completed prior to the appointment. Contacts patient if insurance coverage issues arise during the referral process so that patient can work directly with the insurance company. Manage complex patient interactions related to referral decisions, effectively de-escalating concerns while maintaining adherence to clinical and organizational standards
• Promotes the Atrius Health System of Care by highlighting internal providers and their expertise
• As needed, places orders to start the referral process for the PCP on behalf of patients who have booked appointments and call for the referral
• Researches the visit notes to determine if a referral was intended as well as processing referrals for follow-up or annual visits that require a referral
• Schedules patients for tests, consultations, services and procedures with other departments, local private offices, and/or outside vendors/providers
• Answers phone calls, faxed requests and other inquires relating to referrals and communicates with the physicians and clinicians to acquire authorization or to inform them of patient issues or clinical paperwork needed
• Research questions/concerns from patients regarding bills and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process. Refers patients to appropriate staff (e.g., patient account representatives) for billing issues related to insurance benefits and services covered under the benefits plan
• Works in collaboration with the person designated as the Practice's Benefits Coordinator to maintain cost control, ensure that services provided are within benefit plan guidelines, and that necessary policies and procedures are followed when dealing with non-preferred providers/vendors. May coordinate second opinion requests
• Works with supervisors to ensure patients are receiving timely responses and detailed answers to their complex questions
• Research questions/concerns from patients regarding billing and determines if issue is related to the referral process. Assists in resolving billing and denied referral matters as they relate to the referral process.
• Receives escalated issues and stat same day calls; determine appropriate action and/or works with clinical team for decision
• Effectively deescalates issues with upset patients and practices. Uses advanced listening techniques to understand the issue and give patients options as they are available. Escalates to supervisors only as needed
• Supports roles within the Navigator. Trains and teaches as needed
• Participates in problem solving activities, focusing on productivity and quality. Works with supervisors to ensure continuous improvement of the department
• If needed, contacts appropriate parties to obtain referral authorizations and verify coverage (e.g., the Authorization Services Unit (ASU), National Imaging Associates (NIA) or individual insurance companies). Certain departments may also need to contact additional outside agencies for approval (e.g., American Imaging Management or Med Solutions)
• Accesses only the minimum necessary protected health information (PHI) for the performance of job duties. Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc.) taking reasonable precautions to prohibit unauthorized access. Complies with all Atrius Health and departmental privacy policies, procedures and protocols. Follows HIPAA privacy guidelines without deviation when handling protected health information
• Ability to work in a busy office environment with frequent deadlines and interruptions
• Performs other duties as assigned

What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions 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 Diploma/GED
• 1+ years of experience in a clinical or healthcare setting
• Intermediate level proficiency in Microsoft, scheduling software and electronic medical records systems (Epic or equivalent)

Preferred Qualifications:

• 3+ years of experience in a clinical or healthcare setting
• Experience in a managed care environment
• High level of understanding of health insurance products and limitations in order to match patient to available providers
• Bilingual
• Strong problem solving and complex patient management skills

Soft Skills:

• Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations
• Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance
• Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents
• Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager
• Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers
• Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers
• Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations
• Teamwork: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members

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

Pay is based on several factors including but not limited