Remote Senior DRG Appeals RN

Sustainable World, Inc.; Plymouth, Northern (MN, KY); Hybrid; USD 73,000 - 131,000; Full time

Job summary

UnitedHealth Group's Optum Insight is seeking a Senior Clinical Appeals RN to audit MS-DRG/APR-DRG cases, review records, and draft rebuttals or agreements. You will coach other auditors and guide clinical and coding judgments to improve outcomes.

This remote role allows work from anywhere in the U.S., with opportunities to collaborate across teams and contribute to risk adjustment, policy interpretation, and quality assurance while meeting tight deadlines.

Qualifications

• Unrestricted RN license in your state of residence.
• CCS or CIC certification or willing to obtain within 6 months of hire.
• 2+ years of ICD-10-CM coding including knowledge of principal diagnosis selection, CCs and MCCs, and conditions that impact SOI and ROM.
• 2+ years of ICD-10-PCS coding including knowledge of body systems, root operations, body parts, approaches, devices, and qualifiers.

Responsibilities

• Analyze scope and resolution of DRG Appeals.
• Respond to Level one, two or higher appeals.
• Perform complex conceptual analyses.
• Identify risk factors, comorbidities, and adverse events to determine if overpayment or claim adjustment is needed.
• Review governmental regulations and payer protocols to recommend appropriate actions.
• Research and prepare written appeals.
• Exercise clinical and/or coding judgment and experience.
• Collaborate with existing auditors, quality and leadership to review medical records.

Skills

RN license

CCS/CIC certification

ICD-10-CM coding

ICD-10-PCS coding

Tools

MS Excel

Job description

UnitedHealth Group's Optum Insight is seeking a Senior Clinical Appeals RN to audit MS-DRG/APR-DRG cases, review records, and draft rebuttals or agreements. You will coach other auditors and guide clinical and coding judgments to improve outcomes.

This remote role allows work from anywhere in the U.S., with opportunities to collaborate across teams and contribute to risk adjustment, policy interpretation, and quality assurance while meeting tight deadlines.