Remote Appeals RN — Clinical Admin & Regulatory Auditor

UnitedHealth Group; Texas; Remote; USD 60,000 - 107,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase and 401k

Job summary

UnitedHealth Group is seeking a Senior Clinical Administrative RN to review member appeals and fair hearing requests from a Texas-based remote location. The role focuses on clinical and chart review, audits, and regulatory alignment within a managed care setting.

The ideal candidate has 5+ years of clinical nursing experience, including utilization management, and at least 3 years in appeals, grievances, or regulatory processes. Texas residency is required.

Qualifications

• Active, unrestricted RN license in Texas.
• 54
• 5+ years nursing experience incl utilization management.
• 3+ years in Appeals/Grievances/Regulatory in managed care.
• 3+ years collaborating with Medical Directors.
• Knowledge of State and Federal regulations.

Responsibilities

• Review determinations and prepare for Fair Hearings with clinical staff.
• Participate in State Fair Hearings and coordinate internal reviews for compliance.
• Review electronic Health Records to validate accuracy of decisions.
• Perform internal quality control reviews and develop improvement recommendations.
• Assist with risk assessment processes implementation.
• Coordinate external audits and reviews.
• Maintain knowledge of regulatory and accrediting body requirements.
• Review denial notices for accuracy and compliance.
• Interact with other departments to ensure alignment.

Skills

Utilization management

Regulatory knowledge

Appeals & grievances

Interdepartmental collaboration

Clinical review

Education

RN license (Texas)

Job description

UnitedHealth Group is seeking a Senior Clinical Administrative RN to review member appeals and fair hearing requests from a Texas-based remote location. The role focuses on clinical and chart review, audits, and regulatory alignment within a managed care setting.

The ideal candidate has 5+ years of clinical nursing experience, including utilization management, and at least 3 years in appeals, grievances, or regulatory processes. Texas residency is required.