[Hiring] Clinical Appeals RN @UnitedHealth Group

Role Description

Join us to start Caring. Connecting. Growing together. If you reside near Boston, MA, you will enjoy the flexibility to telecommute* as you take on some tough challenges.

• Determine whether the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial)
• Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)
• Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation to support PA requests
• Represent MassHealth at appeal hearings
• Defend MassHealth prior authorization decisions by utilizing program specific regulations, medical necessity guidelines, standards of care and best practices
• Represent the MA MLTSS program in a positive, solution-focused manner that embodies our corporate values: Integrity, Compassion, Relationships, Innovation and Performance
• Determine the appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
• Identify solutions to non-standard requests and problems
• Participate in regular meetings to collaborate with supporting leadership and team to ensure operational efficiency
• Assure performance adheres with established quality standards, evidenced based practice guidelines and departmental benchmarks and workflows
• Act as a resource for others; provide explanations and information on difficult issues
• Minimum 10% travel within the state of MA

Qualifications

• Associate's degree in Nursing
• Unrestricted RN license required in the state of Massachusetts
• 3+ years HCBS, LTSS clinical experience in case management and utilization management
• Designated workspace and access to install secure high-speed internet via cable or DSL in home
• Reside in the state of Massachusetts

Requirements

• Prior-Authorization experience
• Utilization Management experience
• Appeals Experience
• Medicare/Medicaid experience preferred
• Proficient with Microsoft Office programs, including Word, Excel, PowerPoint
• Excellent communications skills, including the ability to write clearly, succinctly and in a manner that appeals to a wide audience
• Excellent time management, organizational, and prioritization skills with ability to balance multiple priorities

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)
• Hourly pay for this role will range from $29 - $52 per hour based on full-time employment