Clinical Appeals RN - Remote in US

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come.

The Clinical Appeals RN is responsible for providing expertise in clinical appeals and grievances (analyzing, reviewing and evaluating appeals and grievances), and acting as a Clinical Interface Liaison (clinical problem solver with facilities, providers, carriers, resolution of issues concerning members, benefits, program definition and clarification).

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

• Review medical records and verify if the requested service meets criteria
• Review post service claims for clinical eligibility for coverage as prescribed by the Plan benefits
• Review and interpret Plan language
• Coordinate reviews with the Medical Director
• Utilize clinical guidelines and criteria
• Accurately documenting determinations
• Adherence to all confidentiality regulations and agreements
  
  

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• Active, unrestricted RN license in state of residence
• Ability to obtain additional nurse licenses in additional states (WA license and other states as needed)
• 3+ years of clinical experience as an RN including in an acute, inpatient hospital setting
• Experience in one of the following areas Utilization Management, pre-authorization, claim review, appeals review or medical record review
• Solid computer skills including proficiency in Microsoft Office Word, Outlook, and Internet applications
• Designated HIPPA compliant home workspace
• Ability to work until at least 5:00 PM in time zone unless in EST then work hours are until 6:00 pm EST
• Access to install secure high-speed internet (minimum speed 1.5 download mps & 1 upload mps) via cable / DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement)
  
  

Preferred Qualifcations

• Bachelor of Science in Nursing
• Experience using MCG and/or Interqual
• Medical Coding experience / knowledge
• Experience in Medicaid
• Proven excellent communication, interpersonal, problem-solving, and analytical skills
• Proven ability to work independently
• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
  
  

The hourly range for this role is $28.61 to $56.06 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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: 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.