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. Are you ready for a new path? Start doing your life's best work.(sm) 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).
If you are located in the Pacific and Mountain Time Zones, you will have the flexibility to telecommute* as you take on some tough challenges.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
- Responsible for accurately documenting determinations
- Adherence to all confidentiality regulations and agreements
- Tuesday through Saturday 10 hour shifts beginning at 730 or 800am PCT
- Comfortable working mandatory overtime
- Active, unrestricted RN license in state of residence
- 2+ years clinical experience as an RN including in an acute, inpatient hospital setting
- Strong proficiency in Microsoft Office Word, Outlook, and Internet applications
- Ability to support Mountain Time Zone or Pacific Time Zone
- Experience using MCG and/or Medicare criteria
- Utilization Management, pre-authorization, concurrent review or appeals experience
- Bachelor of Science in Nursing
- Excellent communication, interpersonal, problem-solving and analytical skills
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy
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.
Job Keywords: Appeals, claims, MCG, Interqual, Utilization Management, Pre- authorization, Concurrent Review, Medical coding, Telecommute, Telecommuting, Telecommuter, Remote, Work from home, Pacific Time Zone, Mountain Time Zone