IBR Clinical Appeals Analyst - Remote

University of Minnesota School of Nursing; Plymouth (MN); Remote; USD 100,289,000 - 180,521,000; Full time

Job summary

UnitedHealth Group seeks an experienced Clinical Appeals Reviewer for the Itemized Bill Review (IBR) team. The role analyzes appeals, reviews medical records, and drafts written responses with coding and auditing expertise. Remote work within the U.S.

is available, with standard 8:00am–5:00pm hours and potential overtime. Responsibilities include resolving Level 1–3 appeals, identifying overpayments, and ensuring compliance with CPT/NCCI and ICD-10 coding.

Qualifications

• Undergraduate nursing degree required.
• Unrestricted RN license required.
• 2+ years of appeals experience (coding or auditing).
• Experience with CPT-4 coding, NCCI edit resolution and appropriate modifier use.
• Advanced experience with regulations, compliance and composing professional appeal responses.
• Advanced experience with ICD-10-CM and ICD-10-PCS coding.
• Willingness to work 8:00am–5:00pm U.S. business hours.
• Candidates must maintain patient data privacy.

Responsibilities

• Analyze scope and resolution of IBR Appeals.
• Respond to Level 1, 2 or higher appeals.
• Perform complex conceptual analyses.
• Identify risk factors and determine if overpayment or adjustment is needed.
• Review governmental regulations, payer protocols and medical policy.
• Prepare written appeals and document clinical judgments.
• Collaborate with analysts and leadership to review medical records.
• Navigate web portals and online tools (Word, Excel, etc.).
• Serve as a resource on complex issues and develop innovative solutions.
• Define and document business requirements.

Education

Undergraduate nursing degree

Unrestricted RN license

Tools

CPT-4 coding

NCCI edit resolution

ICD-10 CM coding

ICD-10 PCS coding

Job description

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.

The Itemized Bill Review (IBR) Clinical Appeals Reviewer will analyze and respond to client and/or hospital claim review appeal inquiries. Handles medical record review, analyzes data, and completes the response resolution for clients and the business unit. Must utilize expertise in auditing to review and provide response to appeals. We are seeking self-motivated, solution-oriented and skilled problem solver who provides clinical reviews with written documentation under tight deadlines.

This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends.

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

Primary Responsibilities:

• Analyze scope and resolution of IBR Appeals
• Respond to Level one, two or higher appeals
• Perform complex conceptual analyses
• Identifies risk factors, comorbidities', and adverse events, to determine if overpayment or claim adjustment is needed
• Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions
• Researches and prepares written appeals
• Exercises clinical and/or coding judgment and experience
• Collaborates with existing analysts, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims
• Navigates through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel
• Serve as a key resource on complex and / or critical issues and help develop innovative solutions
• Define and document / communicate business requirements

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:

• Undergraduate nursing degree
• Unrestricted RN (registered nurse) license
• 2+ years of appeals experience (coding or auditing)
• Experience with CPT-4 coding, NCCI edit resolution and appropriate modifier use
• Advanced experience with regulations, compliance and composing professional appeal responses
• Advanced experience with ICD10 CM coding and ICD 10 PCS coding
• Willing or ability to work our normal business hours of 8:00am - 5:00pm
• Proven ability to keep all company sensitive documents secure (if applicable)
• Have a dedicated work area established that is separated from other living areas and provides information privacy
• Live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

Preferred Qualifications:

• Clinical claim review experience
• Managed care experience
• Investigation and/or auditing experience
• Advanced experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry
• Knowledge of health insurance business, industry terminology, and regulatory guidelines

*All employees working remotely 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 $35 - $63 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

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.