Senior Clinical Appeals RN

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Hospital Bill Audit Senior Clinical Appeals RN is primary responsibility is to utilize clinical and auditing knowledge to review HBA appeals and provide responses based on client reimbursement policies and HBA auditing standards. Also, this role may review some appeals prepared by other team members when additional review is needed. The Sr Appeal RN acts as a SME to the Hospital Bill Audit (HBA) team to assist in any appeal related need. This role has input into auditing policy and standards. The appeals reviewed are from percent of charge audits. These are not medical necessity or DRG appeals/audits.

You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Analyze HBA appeals received from providers and provides logical, professionally written, concise, appeal responses based on HBA claims utilizing client reimbursement policies to determine if claims are appropriate for hospital bill audit
• Utilize proprietary workflow systems to document appeal actions
• Utilize nursing knowledge to apply interpretation of client reimbursement policies to provide appeal responses
• Review appeal responses created by other appeal team members as needed
• Works collaboratively with operations team RNs to develop appeal responses as new clinical appeal scenarios evolve
• Effectively communicate with leadership and nursing operations team members regarding trends in appeals
• Maintain and manage appeal assignments independently, maintaining standards for productivity and accuracy
• Review and handle emails involving communication with other internal staff in a professional and timely manner
• Acts as a SME for the HBA team for appeals and represent the HBA team in client and provider meetings
• Will be working in production environment with time sensitive client mandated deadlines and attention to detail is required
• Performs other similar and related duties as required or directed

Primary Responsibilities:

• Integrity Value: Act Ethically:
  • Comply with Applicable laws, regulations, and policies
  • Demonstrate Integrity
• Compassion Value: Focus on Customers
  • Identify and exceed customer expectations
  • Improve customer experience
• Relationship Value: Act as a team player
  • Collaborating with others
  • Demonstrate Diversity Awareness
  • Learn and Develop
• Relationship Value: Communicate Effectively
  • Influence others
  • Listen actively
  • Speak and write clearly
• Innovation Value: Support Change and Innovation
  • Contribute innovative ideas
  • Work effectively in a changing environment
• Performance Value: Make Fact-Based Decisions
  • Apply business knowledge
  • Use sound judgment
• Performance Value: Deliver Quality Results
  • Drive for results
  • Manage time effectively
  • Produce high-quality work
    

What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
• More information can be downloaded at: http://uhg.hr/uhgbenefits

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:

• Associate degree in nursing (BSN preferred)
• Current RN license
• 2+ years of clinical experience in an acute care hospital specifically in O.R., specialty/critical care or utilization management

Preferred Qualifications:

• Experience in HBA audits or previous HBA appeal experience
• Ability to read and interpret medical business correspondence, procedure manuals, and specific plan documents. Superior writing skills
• Proficiency in Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry
• Strong analytical and problem-solving skills
• Strong interpersonal skills to build and maintain positive working relationships with colleagues, stakeholders and healthcare providers by facilitating open and constructive communication
• Actively participate in team meetings and contribute to group discussions, sharing knowledge and expertise to promote collective growth
• Ability to prioritize tasks and manage time effectively

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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 employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

#RPO #GREEN