Clinical Appeals RN

Palo Verde Community College District; Boston, Northern (MA, KY); Hybrid; USD 82,925,000 - 148,514,000; Full time

Job summary

Optum in the US is seeking a Clinical Appeals RN in Massachusetts to handle MassHealth appeal hearings and pre-service reviews, with remote work option for MA residents. You will defend authorization decisions using clinical guidelines and collaborate with leadership to ensure efficiency.

The role requires MA RN licensure, an Associate degree in Nursing, and 3+ years in managed care or clinical settings; travel within MA is expected.

Qualifications

• Associate degree in Nursing and MA RN license required.
• 3+ years managed care or clinical experience.
• Reside in Massachusetts and have a designated home workspace.

Responsibilities

• Represent MassHealth at appeal hearings.
• Defend prior authorization decisions using regs and guidelines.
• Support MA MLTSS values: Integrity, Compassion, Relationships, Innovation, Performance.
• Evaluate inpatient/outpatient services per guidelines and benefits.
• Propose solutions to non-standard requests.
• Attend regular leadership and team meetings for efficiency.
• Ensure adherence to quality standards and workflows.
• Serve as a resource, explaining difficult issues.
• Travel within MA at least 10%.

Skills

Excellent communication skills

Time management

Organizational skills

Prior-Authorization experience

Education

Associate's degree in Nursing

Tools

Microsoft Office

Job description

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 makes 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 Clinical Appeals RN is responsible for attending appeal hearings, defending MassHealth prior authorization decisions, and performing pre-service/prior authorization clinical coverage review of services. Works closely with managers and peers.

If you currently reside in the state of Massachusetts, you'll enjoy the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

• Represent MassHealth at appeal hearings
• Defend MassHealth prior authorization decisions by utilizing program specific regulations, medical necessity guidelines, standards of care and best practices
• Represents the MA MLTSS program in a positive, solution-focused manner that embodies our corporate values: Integrity, Compassion, Relationships, Innovation and Performance
• Determine the appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
• Identify solutions to non-standard requests and problems
• Participate in regular meetings to collaborate with supporting leadership and team to ensure operational efficiency
• Assures performance adheres with established quality standards, evidenced based practice guidelines and departmental benchmarks and workflows
• Act as a resource for others; provide explanations and information on difficult issues
• Minimum 10% travel within the state of MA

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.)

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions 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's degree in Nursing
• Unrestricted RN license required in the state of Massachusetts
• 3+ years of Managed Care and/or clinical experience
• Designated workspace and access to install secure high-speed internet via cable or DSL in home
• Reside in the state of Massachusetts

Preferred Qualifications:

• Prior-Authorization experience
• Utilization Management experience
• Appeals Experience
• Medicare/Medicaid experience preferred
• Proficient with Microsoft Office programs, including Word, Excel, PowerPoint
• Excellent communications skills, including the ability to write clearly, succinctly and in a manner that appeals to a wide audience
• Excellent time management, organizational, and prioritization skills with ability to balance multiple priorities

*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 $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

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.