Clinical Appeals RN — Day Shift, Health Plan Expert

UnitedHealth Group; California; Remote; USD 39,000 - 70,000; Full time

Job summary

UnitedHealth Group is seeking a Clinical Appeals RN to provide expertise in clinical appeals and grievances, analyzing and evaluating appeals, and serving as a Clinical Interface Liaison to resolve issues on member benefits and program definitions.

The role involves reviewing medical records, pre-service eligibility, and interpreting Plan language, with coordination with the Medical Director and adherence to confidentiality requirements. Overtime is mandatory in this position.

Qualifications

• Active, unrestricted RN license in state of residence.
• 2+ years of clinical RN experience, including acute inpatient hospital setting.

Responsibilities

• Review medical records and verify if the requested service meets criteria.
• Review pre-service appeals for clinical eligibility for coverage.
• Review and interpret Plan language.
• Coordinate reviews with the Medical Director.
• Utilize clinical guidelines and criteria.
• Accurately document determinations.
• Adhere to all confidentiality regulations and agreements.
• Comfortable working mandatory overtime.

Education

Active, unrestricted RN license in state of residence

Job description

UnitedHealth Group is seeking a Clinical Appeals RN to provide expertise in clinical appeals and grievances, analyzing and evaluating appeals, and serving as a Clinical Interface Liaison to resolve issues on member benefits and program definitions.

The role involves reviewing medical records, pre-service eligibility, and interpreting Plan language, with coordination with the Medical Director and adherence to confidentiality requirements. Overtime is mandatory in this position.