Clinical Appeals RN - Remote - Work PST hours

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

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. 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. Solid computer and software navigation skills are critical. You should also be patient-focused and adaptable to changes. In addition, you will be accountable for maintaining compliance with policies and procedures. 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. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

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 Exceptional 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