Senior Clinical Appeals RN

Senior Clinical Appeals RN

$10,000 SIGN ON BONUS FOR EXTERNAL APPLICANTS

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing Together.

The Senior Clinical Appeals RN utilizes subject matter expertise in MS-DRG and APR-DRG auditing to review and provide response to appeals. By partnering with the original auditor, review medical records, and other information to author a rebuttal or agreement with the facility. This person will be instrumental in providing coaching and education to our remote DRG Validation Specialists utilizing core coding and clinical information. We are seeking self-motivated, solution oriented and skilled problem solvers who provide written documentation under tight deadlines. As a Senior Clinical Appeals RN, you will derive key insights from the appeals and provide guidance and direction to fellow auditors across our business.

You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary 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 and/or medical policy to recommend appropriate actions
• Research and prepare written appeals
• Exercise clinical and/or coding judgment and experience
• Collaborate with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims
• Navigate through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel
• Serve as a key resource on complex and/or critical issues and help develop innovative solutions
• Define and document/communicate business requirements

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Associate's degree (or higher)
• Unrestricted RN (Registered Nurse) license in your state of residence
• CCS or CIC or ability to obtain certification within 6 months of hire
• 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
• Advanced level of proficiency with ICD-10-CM coding including knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs) and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
• Advanced level of proficiency with ICD-10-PCS coding including knowledge of the structural components of PCS including but not limited to, selection of appropriate body systems, root operations, body parts, approaches, devices and qualifiers

Preferred Qualifications:

• Managed care experience
• Healthcare claims experience
• Investigation and/or auditing experience
• Knowledge of health insurance business, industry terminology and regulatory guidelines
• Proficiency with MS Excel including the ability to create/edit spreadsheets and use sort/filter function
• An existing coding certification, such as RHIT (registered health information technician), RHIA (registered health information administrator), CDIP (certified documentation improvement practitioner), CCS (certified coding specialist), CIC (certified inpatient coder) or CPC (certified professional coder)

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

**PLEASE NOTE** The sign-on bonus is only available to external candidates. Candidates who are currently working for UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time or per diem basis ("Internal Candidates") are not eligible to receive a sign on bonus.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.