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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Location: This role is available in the following locations Alabang, Davao, Cebu, Taguig, Makati and Quezon City

Primary Responsibilities:

• Checks the benefit plan coverage of the member and review their condition against United Health Care's Medical Policy if the procedure they're requesting will be approved or not
• Perform clinical coverage review of services, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
• Complete approval coverage determinations according to applicable medical policy and guidelines
• Prepares cases for physician review
• Function as a member of a self-directed team to meet specific individual and team performance metrics
• Be able to communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines, contractual limitations, and reimbursement determinations
• Telephonic discussion with health care providers and members to explain benefit coverage and medical necessity determinations and to obtain additional clinical information
• Acts as a resource for others with less experience
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• Undergraduate degree or equivalent experience
• Registered nurse with an US mainland active license
• With at least 1 year of Clinical and bedside experience or any UM/ UR related experience
• With or without BPO experience
• Proven computer skills

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

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.

Diversity creates a healthier atmosphere: Optum 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.

Optum is a drug-free workplace. © 2023 Optum Global Solutions (Philippines) Inc. All rights reserved.