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We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM


Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com


Job Category:




Approximate Salary:

Not Specified

Position Type:

Full Time

Senior Clinical Appeals RN – New Hyde Park, NY


Posted: 11/17/2018

If you're looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.(sm)
This is an office based role located at Northwell in New Hyde Park, NY. This is a daytime position, potential for a 4 or 5 day work week depending on how many hours you work a day.
Primary Responsibilities:
  • Coordinates appeals process
  • Sorts, reviews and evaluates cases denied by all payers and determines follow through for first, second and third level appeals within contractual or appropriate timeframes
  • Monitors inpatient denials and assists patients and physicians with management of the appeals process
  • Writes first, second and third level insurance appeal letters
  • Reviews and coordinates utilization issues concurrently and retrospectively related to denials from all payer's
  • Maintains data tracking systems and identifies Utilization trends
  • Serves as a resource to all hospital staff related to Utilization Management issues
  • Promotes staff development and education
  • Assesses and monitors of quality issues, and follows-up with Quality Management
  • Attends committee and staff meetings, as required
  • Keep abreast of all changes in policies and procedures relating to Utilization Management and Case Management
  • Performs related duties as required

Required Qualifications:
  • Current, unrestricted  license to practice as a Registered Professional Nurse in New York State
  • 3+ years recent/current clinical experience in the acute care setting
  • BSN degree
  • Proficient in Microsoft office – basics on Word, Excel and Outlook
Preferred Qualifications:
  • 1+ years Case Management Experience in the hospital setting
  • Experience working in utilization management or appeals on the insurance side
  • Hospital-based experience writing appeals to refute clinical denials
  • 1+ years of clinical experience including, utilization management, discharge planning; third party payment systems; and appeals and denial processes
  • Medical Coding or CDI experience
  • Experience with Sunrise EMR
Health care isn't just changing. It's growing more complex every day. ICD10 replaces ICD9. Affordable Care adds new challenges and financial constraints. Where does it all lead? Hospitals and health care organizations continue to adapt, and we are a vital part of their evolution. And that's what fueled these exciting new opportunities.

Optum360 is a dynamic new partnership formed by Northwell Health and Optum to combine our unique expertise. As part of the growing family of UnitedHealth Group, we'll leverage all our resources to bring financial clarity and a full suite of revenue management services to health care providers nationwide.

If you're looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.(sm)
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: New York, NY, New Hyde Park, utilization management, case management, ICD 10, appeals, Quality

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