Clinical Appeals Registered Nurse
Title: Clinical Appeals RN - Remote - M-F working alternating Saturdays Location: United States Work Type: Remote, Full Time Job ID: 2367603 Job Description: 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. 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. Please note this team has a schedule as follows - M-F, 8:00- 4:30 in their time zone and alternating Saturdays (2 per month with a weekday off when working a Saturday) .
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 documenting determinations
- Adherence to all confidentiality regulations and agreements
- Hours M-F 8a-5p with alternating Saturdays
- Comfortable working mandatory overtime
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
- 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 M-F, 8:00- 4:30 in their time zone and alternating Saturdays (2 per month with a weekday off when working a Saturday)
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
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits re subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable. 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