Clinical Claims Review RN - Appeals and Grievances - Remote Nevada

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.

Under direct supervision of the Manager, Customer Response and Resolution/Appeals & Grievances, conducts full and fair reviews of member and provider appeals. The nurse, utilizing standardized criteria, protocols, and guidelines, conducts retrospective, concurrent and prospective reviews for appropriateness of diagnostic procedures, inpatient stay, ambulatory services, emergency department visits, evaluation & management services, coding levels, etc.,

This RN will train and provide coverage for the Appeals & Grievances in Clinical Claims Review.

You’ll enjoy the flexibility to work remotely * in Nevada within the U.S. as you take on some tough challenges.

Primary Responsibilities
• Provide support to all units within CR&R to ensure Star Ratings are not jeopardized and all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities
• Identify business priorities and necessary processes to triage and deliver work
• Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes
• Consider, review and evaluate appeals in compliance with state and federally mandated turn- around-times and process requirements
• Ensure that all necessary clinical information is available to allow for a full and fair review
• Outreach as necessary to provider/provider staff for clarification or additional information needed
• Prepare claims and case summary for MD review and appropriate decision
• Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements
• Access and review various resources to support denial or overturn denial (i.e. MCG)
• Participate in various special projects as assigned
• Attend assigned meetings relating to clinical reviews and other aspects of job function
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines

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
• Current, unrestricted RN license for the state of Nevada
• 5+ years of clinical nursing experience

Preferred Qualifications
• Bachelor’s degree
• Managed care experience
• Knowledge of managed care delivery system concepts such as HMO/PPO
• Knowledge of evidenced based and standardized criteria such as MCG
• Broad knowledge of medical conditions, procedures and management
• Proficiency with MS Word, Excel and Outlook
• Proven ability to learn and differentiate between company products and the benefits

Soft Skills
• Excellent written and verbal communication skills
• Superb time management skills
• Ability to work with a diverse clinical and non-clinical team
• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.

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.

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