Clinical Appeals RN - Remote in EST or CST Time Zone

MedStar Health; Charlotte (NC); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking an RN for appeals assessment and decision-making roles in a fast-paced environment. The position requires strong clinical judgment and experience in managed care settings. The successful candidate will work collaboratively and independently, ensuring quality care and compliance with policies.

Benefits

Comprehensive benefits package

Incentive and recognition programs

401k contributions

Qualifications

• Current, valid RN licensure in state of residence.
• 2+ years of clinical experience in acute care or outpatient setting.
• Experience in Utilization Review or Medicare/Medicaid appeals.

Responsibilities

• Perform initial assessment review of appeals and medical records.
• Identifying additional information needed for appeals processing.
• Utilize clinical judgment to make decisions on nurse level cases.

Skills

Clinical nursing judgment

Critical thinking

Microsoft Office

Adaptability

Education

RN licensure

Job description

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 startCaring. Connecting. Growing together.

If you are located within Eastern Standard time zone, you will have the flexibility to work remotely* as you take on some tough challenges.The work schedule is generally Monday-Friday, 8-5 EST or 8-5 CST.

Primary Responsibilities:

• Perform initial assessment review of appeals, medical records, and CMS/State Policies to determine if care/services provided meets coverage and billable criteria to be paid


• Identify if additional information is required to process an appeal


• Ability to adapt to changes that require cross training on appeal types as they are identified


• Ability to work independently


• Utilize Clinical nursing judgment assessment and critical thinking skills, guided by regulatory policy, to make decision on administrative nurse level cases


• Ability to navigate multiple computer programs, moving from one system to another, while managing multiple tasks and priorities

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, valid, and unrestricted RN licensure in your state of residence


• 2+ years of clinical experience in an acute care or an outpatient setting


• 1+ years of direct experience within one (or more) of the following areas:
  
  
  
  • Utilization Review
  
  
  • Medicaid and/or Medicare appeals experience
  
  
  • LOC assessment planning and Discharge SNF Planning including understanding of Denial Notice and NOMNC
  
  
  
  


• Proven experience/understanding of billable services and claims in a managed care environment


• Solid Microsoft Office (Word, Excel & Outlook) Basic computer skills


• Access to high-speed internet


• Ability to work 8-5 within EST (Eastern standard time zone)

Preferred Qualifications:

• 5+ years of Medical Appeal experience working with Medicare and Medicaid


• Solid coding experience or Certified Coder (CPC)

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

The hourly range for this role is $28.61 to $56.06 per hour based on full-time employment. 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.

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.