Remote RN Appeals Specialist — Senior Clinical Admin

UnitedHealth Group; Houston (TX); Remote; USD 60,000 - 107,000; Full time

Job summary

UnitedHealth Group is seeking a Senior Clinical Administrative RN to support Texas remote reviews of appeals and fair hearings. The role emphasizes clinical review, chart audits, and collaboration with cross-functional teams to ensure accurate determinations and compliance.

In Texas, you may telecommute while handling state/federal regulatory review, audits, and external coordination. Strong attention to detail and communication are essential for success in this role.

Qualifications

• Active, unrestricted RN license in Texas.
• 5+ years of clinical nursing experience, including utilization management, medical necessity review, care management, or related clinical decision-making.
• 3+ years of experience with Appeals, Grievances, or Regulatory processes in a managed care or health plan environment.
• 3+ years of experience with knowledge of State and Federal Regulations.
• 3+ years of experience collaborating with Medical Directors, clinicians, or cross-functional partners to support clinical decisions.
• Intermediate level of proficiency with clinical systems and Microsoft Office suite (PowerPoint, Word, Excel, and Outlook).

Responsibilities

• Works with clinical and non-clinical staff to review determinations and prepare for Fair Hearings.
• Participates in State Fair Hearings.
• Coordinates internal reviews on denial letters to determine compliance with contractual and regulatory requirements of the State and Federal programs, while reviewing for efficiencies and effectiveness of procedures.
• Reviews electronic Health Records to validate accuracy of decision, recommend revisions, additional documentation, or action to take based on independent review.
• Performs internal Quality Control reviews on processes and activities while developing recommendations for improvement.
• Serves as a catalyst for implementing an appropriate risk assessment process designed to identify and correct deficiencies.
• Assists with the coordination of external audits and reviews conducted by our clients or contracting organizations.
• Maintain extensive knowledge of regulatory and applicable accrediting body requirements becoming a Compliance resource for the team.
• Proficient in interpreting benefits, contracts, and medical policy.
• Review denial notice issued by the National Letter team to ensure accuracy and compliance, as well as providing recommendations for improvement, as needed.
• Interact effectively with other departments.
• Maintain knowledge of State rules, contracts, and Federal legislation/regulations as well as UHG guidelines.
• Establish and maintain good working relationships throughout the company to support goals and objectives.
• Demonstrate flexibility, availability, and dependability to conform to position responsibilities.
• Ability to work independently or in a team environment.
• The applicant should possess a high attention to detail, exceptional documentation abilities, and organizational skills

Skills

Clinical nursing

Utilization management

Regulatory knowledge

Collaboration with clinicians

Attention to detail

Education

Active RN license in Texas

Tools

MS Office

Job description

UnitedHealth Group is seeking a Senior Clinical Administrative RN to support Texas remote reviews of appeals and fair hearings. The role emphasizes clinical review, chart audits, and collaboration with cross-functional teams to ensure accurate determinations and compliance.

In Texas, you may telecommute while handling state/federal regulatory review, audits, and external coordination. Strong attention to detail and communication are essential for success in this role.