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Regulatory Appeals RN - Telecommute in CA

Company: Optum
Location: Cypress
Posted on: September 20, 2022

Job Description:

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)If you're interested in bringing your nursing experience to a role that offers regular, Monday through Friday business hours and ample potential for advancement, apply to join us as one of our newest Clinical Admin Nurses!This position will handle the clinical review of Commercial HMO Regulatory Appeals and will be responsible for completing both standard and expedited member Regulatory Appeal requests. Standard Regulatory Appeals must be completed within 5 days. Expedited Regulatory Appeals must be completed within 24-72 hours. Requires telephone communication with state regulator contacts to explain or defend UHC's position based on the member's benefit, medical necessity criteria, and/or case outcomes. Requires communication with Medical Groups and/or provider offices for records, case effectuation and any other case related information. Requires occasionally telephone communication with California state regulator contacts. Requires completion of clear and concise, written correspondence to the California state regulator of the researched outcome.Must be able to work 8:00am - 5:00pm Pacific Standard TimeIf you are located in in CA, you will have the flexibility to telecommute* as you take on some tough challenges. Primary Responsibilities:

  • Address Standard and Expedited Regulatory Appeal cases
  • Complete Standard Regulatory Appeal cases within 5 calendar days
  • Complete Expedited Regulatory Appeal cases within 24-72 hours
  • Thoroughly research issues to clearly and concisely address the concerns identified in the complaint
  • Work closely with a variety of internal departments (i.e. Appeals & Grievance, Claims, Membership Eligibility)
  • Communicating directly with physicians, UM departments, provider financial offices
  • Current, unrestricted RN license for the State of CALIFORNIA
  • Knowledge of and/or experience with HMO and Managed Care
  • Solid computer proficiency
  • Solid organizational skills, must be detail oriented
  • Solid communication skills - written and verbal
  • Must be able to work with established deadlines and quick turnaround times
  • Make referrals to outside sourcesThis is a fast paced, production environment. You'll need to be efficient, productive and thorough, dealing with our internal and external business partners both verbally and in writing. Strong computer and software navigation skills are critical. You should also be strongly patient-focused and adaptable to changes. In addition, you will be accountable for maintaining compliance with policies and procedures.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:
    • Current, unrestricted REGISTERED NURSE (RN) license in the State of CALIFORNIA (regardless of residency)
    • 3+ years of clinical experience in a hospital or other acute care setting
    • Able to work 8:00am - 5:00pm PST (regardless of residency)Preferred Qualifcations:
      • BSN degree or higher
      • Appeals experience
      • CPT, HCPC, ICD-9 and ICD-10 coding experience
      • Utilization review and/or case management experience
      • Experience in a telephonic or office-based role
      • Expertise at providing customer service and deescalating stressful situations and conversations
      • Creative problem-solving skills
      • Ability to optimize resources using excellent clinical judgment
      • Ability to navigate a Windows based environment, utilizing excellent typing skills (including spelling and grammar)
      • Ability to evaluate and interpret medical records (all specialties)
      • Ability to thoroughly research issues and analyze the findings to deliver case outcomes
      • Ability to work independently with minimal supervision
      • An attitude that fosters teamwork and supports organizational goals
      • Solid team player
      • Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodationTo protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employmentCareers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 5 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

Keywords: Optum, Cypress , Regulatory Appeals RN - Telecommute in CA, Healthcare , Cypress, California

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