Clinical Appeals RN – Remote – M-F working alternating Saturdays
2378522 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
- 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)
- 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
