Clinical Appeals RN

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. 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.

Primary Responsibilities:

• 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
• Represents 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
• Assures 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%25 travel within the state of MA

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions 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 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

Preferred Qualifications:

• 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

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

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). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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