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Clinical Appeals RN - Commercial Plan (Weekend Shift) - Remote
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 optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. This role will require the a****bility to work a on Saturday either in a traditional 5 day work week schedule or working 4-10 hour shift but MUST be able to work until 5pm in residing time zone.
Primary Responsibilities:
- Conducts reviews of member and provider appeals
- Analyzes claim adjustment and claim history
- Reviews history of previous reviews
- Reviews denied services in conjunction with policies and procedures, benefit plans, federal and state regulations, and clinical criteria to and renders approval when appropriate
- Extrapolates and summarizes medical information for review by Medical Director, as needed
- Balances the need to produce high quality work with meeting timeframes and production goals
Required Qualifications:
- Active, unrestricted RN license in state of residence
- 5+ years of clinical experience as an RN including in an acute, inpatient hospital setting
- Experience applying benefits and criteria to clinical review
- Utilization Management, pre-authorization, concurrent review or appeals experience
- Solid computer skills including proficiency in Microsoft Office Word, Outlook, and Internet applications
- Ability to access multiple computer platforms
- Access to install secure high-speed internet (minimum speed 5 download mps & 1 upload mps) via cable/DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement)
- Designated quiet workspace in your home (separated from non-workspace areas) and able to be secured to maintain Protected Health Information (PHI) and/or Protected Information (PI)
- Ability to work a on Saturday either in a traditional 5 day work week schedule or working 4-10 hour shifts
- Ability to work until 5pm in residing time zone
- Medical Coding experience/knowledge
- Experience using Interqual
- Experience with the following systems: UNET, iCUE/HSR, ATS, ETS or Cirrus
- Experience analyzing medical records, benefit plans, medical policies and other various criteria
- Demonstrated ability to work independently with solid self-discipline and time management skills
- Demonstrated excellent communication, interpersonal, problem-solving, and analytical skills
- All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
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.
UnitedHealth Group is an Equal Employment Opportunity employe
