Remote TX: Senior Clinical Appeals RN

Optum; United States; Remote; USD 60,000 - 107,000; Full time

Benefits offered by this job

Telecommuter policy

Job summary

UnitedHealth Group's UnitedHealthcare division seeks a Senior Clinical Administrative RN to review member appeals and grievances, assess medical necessity, and prepare for Fair Hearings in Texas. The role supports consumer-oriented health benefits and requires strong documentation and regulatory expertise.

Telecommuting is available in this Texas-focused position. The candidate will review determinations, coordinate with clinical and non-clinical staff, and ensure compliance with state and

Qualifications

• Active Texas RN license required.
• 5+ years clinical nursing experience including utilization management or care management.
• 3+ years experience with Appeals, Grievances, or regulatory processes.
• 3+ years experience with State/Federal Regulations.
• 3+ years experience collaborating with Medical Directors or cross-functional partners.

Responsibilities

• Review determinations and prepare for Fair Hearings.
• Participate in State Fair Hearings.
• Coordinate internal reviews of denial letters for regulatory compliance.
• Review electronic Health Records to validate decision accuracy.
• Perform internal Quality Control reviews and propose improvements.
• Assist with coordination of external audits.
• Maintain knowledge of state and federal regulations and accrediting requirements.

Skills

RN license TX

Clinical nursing

Appeals & grievances

Regulatory knowledge

MS Office

Tools

Microsoft Office

Job description

UnitedHealth Group's UnitedHealthcare division seeks a Senior Clinical Administrative RN to review member appeals and grievances, assess medical necessity, and prepare for Fair Hearings in Texas. The role supports consumer-oriented health benefits and requires strong documentation and regulatory expertise.

Telecommuting is available in this Texas-focused position. The candidate will review determinations, coordinate with clinical and non-clinical staff, and ensure compliance with state and