Senior 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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Senior Clinical Appeals RN utilizes subject matter expertise in MS-DRG and APR-DRG auditing to review and provide response to appeals. By partnering with the original auditor, review medical records, and other information to author a rebuttal or agreement with the facility. This person will be instrumental in providing coaching and education to our remote DRG Validation Specialists utilizing core coding and clinical information. We are seeking self-motivated, solution oriented and skilled problem solvers who provide written documentation under tight deadlines. As a Senior Clinical Appeals RN, you will derive key insights from the appeals and provide guidance and direction to fellow auditors across our business. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Analyze scope and resolution of DRG Appeals Respond to Level one, two or higher appeals Perform complex conceptual analyses Identify risk factors, comorbidities, and adverse events, to determine if overpayment or claim adjustment is needed Review governmental regulations and payer protocols and / or medical policy to recommend appropriate actions Research and prepare written appeals Exercise clinical and/or coding judgment and experience Collaborate with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims Navigate through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel Serve as a key resource on complex and / or critical issues and help develop innovative solutions Define and document / communicate business requirements 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.