Senior Clinical Administrative RN - Remote in Texas

UnitedHealth Group; Texas; A distancia; USD 60.000 - 107.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase and 401k

Descripción de la vacante

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.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Utilization management

Regulatory knowledge

Appeals & grievances

Interdepartmental collaboration

Clinical review

Educación

RN license (Texas)

Descripción del empleo

About This Role

The Senior Clinical Administrative RN role focuses on reviewing member appeals and fair hearing requests, including clinical review, chart review, and audits. This position is ideal for experienced RNs looking to make a significant impact in the healthcare system while working remotely in Texas.

Highlights

• Pay: $60,200 - $107,400/year
• Location: Houston, TX
• Department/Unit: Clinical Administration
• Schedule: Full Time, Day shift
• Residency: Must reside in Texas

What You'll Do

• Work with clinical and non-clinical staff to review determinations and prepare for Fair Hearings
• Participate in State Fair Hearings
• Coordinate internal reviews on denial letters for compliance with regulations
• Review electronic Health Records to validate accuracy of decisions
• Perform internal Quality Control reviews and develop recommendations for improvement
• Serve as a catalyst for implementing risk assessment processes
• Assist with coordination of external audits and reviews
• Maintain knowledge of regulatory and accrediting body requirements
• Review denial notices for accuracy and compliance
• Interact effectively with other departments

Requirements

• Education: Active, unrestricted RN license in the state of Texas
• Experience: 5+ years of clinical nursing experience, including utilization management or related roles
• 3+ years of experience with Appeals, Grievances, or Regulatory processes in a managed care environment
• 3+ years of experience with knowledge of State and Federal Regulations
• 3+ years of experience collaborating with Medical Directors or clinicians
• Licenses & Certifications: Active RN License in Texas required

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase and 401k contribution

About UnitedHealth Group

UnitedHealth Group is a leading healthcare provider committed to delivering exceptional patient care. They focus on simplifying the healthcare experience and creating healthier communities while addressing health disparities and improving health outcomes.