Job description
At UnitedHealthcare, we are 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 reside in Texas, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
• Conduct comprehensive clinical reviews of appealed H6516 and H2060 assessment determinations to ensure accuracy, consistency, and compliance with state and managed care organization requirements
• Evaluate medical records, assessment documentation, service plans, and supporting clinical evidence related to appeals
• Identify discrepancies, omissions, or inaccuracies that may have impacted initial assessment outcomes
• Provide independent clinical judgment regarding medical necessity and functional support needs
• Prepare detailed appeal findings, clinical rationale, and assessment outcomes in a clear and professional manner
• Collaborate with team members throughout the appeal process
• Maintain accurate, timely, and auditable documentation within designated clinical and appeals systems
• This position will be a work at home position working Monday - Friday (days) with some flexibility in hours
You will 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.
Requirements
- • Current unrestricted Texas RN license
• 2+ years of experience working in Medicaid
• 2+ years of experience conducting, reviewing, or auditing H6516 and/or H2060 Personal Assistance Services assessments
• Advanced level of proficiency with computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications
• High-speed internet at residence
• Experience in Medicaid Long-Term Services and Supports (LTSS), managed care, utilization management, case management, appeals, or clinical assessment
• Experience analyzing complex clinical documentation and synthesizing information from multiple sources to support determinations
• Strong written communication skills with the ability to provide clear, concise, and comprehensive appeal summaries and determination documentation
*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 $29.00 to $52.00 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.
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.
#RPO, #GREEN
About UnitedHealth Group / Optum
Optum Home & Community Care is part of UnitedHealth Group and provides telephonic case management services to help members navigate the health care system and access support services. As an RN Case Manager, you would assess members' health status, identify gaps in treatment plans, establish care goals, coordinate with multidisciplinary teams including mental health clinicians, provide patient education and coaching, make referrals to community resources, and facilitate transitions between care settings—primarily through phone calls in a high-volume customer service environment.
