Overview

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. Join us to start Caring. Connecting. Growing together.

Role

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).

Work Arrangement

You will have the flexibility to work remotely from anywhere within the U.S. This role will involve weekend work, usually every other week or every week if working a 4-day work week. Five-day work week schedules are also available.

Primary Responsibilities

• Review medical records and verify if the requested service meets criteria
• Review pre-service appeals 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 document determinations
• Adhere to all confidentiality regulations and agreements
• Hours M-F 8a-5p with alternating Saturdays
• Comfortable working mandatory overtime

Qualifications

Required Qualifications

• Active, unrestricted RN license in state of residence
• 2+ years of clinical experience as an RN, including in an acute, inpatient hospital setting
• Proficiency in Microsoft Office, Word, Outlook, and Internet applications
• Available for 5 day work weeks including weekdays and weekends, 8:00-4:30 in their time zone and some weekend work will be needed

Preferred Qualifications

• Bachelor of Science in Nursing
• 1+ years of experience using MCG and/or Medicare criteria
• 1+ years of Utilization Management, pre-authorization, concurrent review or appeals experience
• Appeals experience
• Proven excellent communication, interpersonal, problem-solving, and analytical skills
• All employees working remotely will be required to adhere to UnitedHealth Group\'s Telecommuter Policy

Compensation and Benefits

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to salary, benefits include a comprehensive package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits subject to eligibility requirements). The hourly pay for this role ranges from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Application and Equal Opportunity

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

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.