[Hiring] Senior Clinical Administrative RN @UnitedHealth Group

Role Description

The role focuses on review of member appeals and fair hearing requests, including:

• Clinical review, chart review, audits, and letter review.
• Working with clinical and non-clinical staff with varied backgrounds to review authorization and UR determinations in preparation for a Fair Hearing with the State of Texas.
• Responsible for reviewing appeals and grievances to determine if the appropriate decision was rendered.
• Empowered to achieve new levels of excellence and make a profound impact in a vital and complex system.
• Flexibility to telecommute if located in Texas.

Primary Responsibilities:

• Works with clinical and non-clinical staff to review determinations and prepare for Fair Hearings.
• Participates in State Fair Hearings.
• Coordinates internal reviews on denial letters to determine compliance with contractual and regulatory requirements.
• Reviews electronic Health Records to validate accuracy of decisions and recommend actions.
• Performs internal Quality Control reviews and develops recommendations for improvement.
• Serves as a catalyst for implementing a risk assessment process to identify and correct deficiencies.
• Assists with coordination of external audits and reviews conducted by clients or contracting organizations.
• Maintains extensive knowledge of regulatory and accrediting body requirements.
• Proficient in interpreting benefits, contracts, and medical policy.
• Reviews denial notices for accuracy and compliance, providing recommendations for improvement.
• Interacts effectively with other departments.
• Maintains knowledge of State rules, contracts, and Federal legislation/regulations.
• Establishes and maintains good working relationships throughout the company.
• Demonstrates flexibility, availability, and dependability.
• Ability to work independently or in a team environment.
• High attention to detail, exceptional documentation abilities, and organizational skills.

Qualifications

• Active, unrestricted RN license in the state of Texas.
• 5+ years of clinical nursing experience, including utilization management, medical necessity review, care management, or a related clinical decision-making role.
• 3+ years of experience with exposure to Appeals, Grievances, or Regulatory processes in a managed care or health plan environment.
• 3+ years of experience with knowledge of State and Federal Regulations.
• 3+ years of experience collaborating with Medical Directors, clinicians, or cross-functional partners.
• Intermediate level of proficiency with clinical systems and Microsoft Office suite (PowerPoint, Word, Excel, and Outlook).

Requirements

• Familiarity with Texas HHSC, Medicaid managed care, or state regulatory requirements.
• Experience supporting LTSS or complex populations.
• Ability and willingness to learn Fair Hearing evidence preparation and State Fair Hearing representation.
• Experience presenting clinical information in a structured, professional setting.
• Demonstrated track record of meeting or exceeding expectations and program goals.
• Strong written and verbal communication skills.
• Proven ability to manage time-sensitive work and meet regulatory or operational deadlines.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (subject to eligibility requirements).
• Salary range: $60,200 - $107,400 annually based on full-time employment.

Company Description

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone deserves the opportunity to live their healthiest life. We are committed to mitigating our impact on the environment and enabling equitable care that addresses health disparities.