Optum · 16 hours ago
Financial Clearance Specialist RN
United States
Full-time
Remote
Mid Level
$60K/yr - $107K/yr
3+ years expOptum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The Financial Clearance Specialist RN will identify requirements for prior authorization, ensure compliance with service level agreements, and manage authorization processes to support patient care in Oncology and other medical specialties.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Identify requirements to obtain prior authorization denials for Oncology services and other medical specialties as needed
Prioritize work per Financial Clearance Service Level Agreements (SLA) and payer deadlines to ensure all patients are cleared per standards in system policies
Identify prior authorization requirements for service(s) by using tools, electronic resources (i.e. electronic queries, payer websites) and/or phone/fax
Complete daily assignments per leadership direction
Assess clinical data from medical records to obtain authorization for scheduled services
Abstract and submit clinical data from medical records to insurance payers Utilize clinical screening criteria and reviews insurance payer medical policies to ensure patients meet medical necessity for scheduled services
Assure the medical record has the proper physician clinical documentation to support medical necessity for the ordered service
Monitor for continued authorization, communicates results and opportunities to nurses, physicians, finance, case managers and payers
Complete work effectively and efficiently maintaining quality and production standards Maintains knowledge of and complies with regulatory requirements, organizational standards, and policies, procedures, and workflows related to areas of responsibility
Evaluate potential denials or payment issues and initiates communication with physicians or clinician regarding next steps
Prepare and facilitates appeals for denied claims, as appropriate
Escalate peer to peer requests to the ordering physician, and provide appropriate insight to the provider regarding clinical documentation to support medical necessity for the ordered service
Summarize denial trends and report to leadership
Complete work effectively and efficiently maintaining quality and production standards
Training/mentoring and daily workflow coaching to less experienced team members on all aspects of the prior authorization process
Other duties as assigned
Qualification
Required
High School Diploma/GED (or higher)
Active licensed Registered Nurse in the state in which you reside
3+ years of Managed Care and/or clinical experience
2+ years of experience in an acute hospital or medical clinic setting
Preferred
Bachelor's Degree in Nursing (or higher)
2+ years of health insurance authorization experience
2+ years of experience using InterQual, MCG, or other clinical criteria
Certified Case Manager (CCM)
Knowledge of Milliman Criteria
Benefits
A comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
Company
Optum
Optum is a healthcare company that provides pharmacy services, health care operations, and population health management. It is a sub-organization of UnitedHealth Group.
10001+ employees
H1B Sponsorship
Optum has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (648)
2024 (559)
2023 (620)
2022 (851)
2021 (593)
2020 (438)
Funding
Current Stage
Late StageLeadership Team
Daniel Castillo
Chief Executive Officer, Optum Care Delivery
J
Jay Green
Chief Financial Officer
Recent News
2025-11-29
2025-11-19
2025-11-07
Company data provided by crunchbase