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Clinical Appeals RN - California

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 appeals and will be responsible for completing both standard and expedited member appeal requests. Standard appeals must be completed within 25-30 days. Expedited appeals must be completed within 24-72 hours. Requires telephone contact with Members and/or providers initiating an appeal to explain the process, criteria, and outcome. Requires contact with Medical Groups and/or provider offices for records and case effectuation. Requires occasionally telephone contact with Members. Requires completion of written correspondence for Member outcome letters.

Must - be able to work 8:00am - 5:00pm Pacific Standard Time. Overtime may be required in order to meet compliance with federal/state turn-around times.

If you are located in the Pacific Time Zone, preferably California, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

Addressing Standard and Expedited appeals cases

Completing a standard number of case volume/day

Completing the Standard appeals cases within 25-30 calendar days

Completing the Expedited appeals cases within 24-72 hours

Researching issues to mitigate risk

Working closely with a variety of internal departments (i.e. Regulatory, Claims)

Communicating directly with Members, medical groups, and physicians

Current, unrestricted RN license for the State of CALIFORNIA

Knowledge of and/or experience with HMO and Managed Care

Solid computer proficiency

Strong typing skills (at least 65 WPM)

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 internal and outside sources

Work Hours: Monday - Friday, 8:00am - 5:00pm PST

*** This is a high-volume, production environment. You'll need to be efficient, productive and thorough dealing with our Members 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 (IRN) -license in the State of California (regardless of residency)

3+ years of clinical experience in a hospital or other acute care setting

Proficient -ability to navigate a Windows based environment, utilizing excellent typing skills (including spelling and grammar)

Ability to evaluate and interpret medical records (all specialties)

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 accommodation

Preferred Qualifications:

BSN degree or higher

Appeals experience

CPT, HCPC, ICD-9 and ICD-10 coding experience

Appeals, Utilization review and/or case management experience

Experience in a production environment either in telephonic or office based role

Expertise at providing customer service and deescalating stressful situations and conversations

Creative problem-solving skills

Solid team player

Ability to optimize resources using excellent clinical judgment

Ability to work independently with minimal supervision

Possesses an attitude that fosters teamwork and supports organizational goals

To 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 employment

Careers 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)

Nevada Residents Only: The hourly range for Nevada residents is $28.85 to $51.30. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.

*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 , Clinical Appeals RN - California, Healthcare , Cypress, California

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