Clinical Appeals RN - California RN Requirement - Telecommute - #19503452

UnitedHealth Group Inc.


Date: Dec 26, 2020
City: Los Angeles, CA
Contract type: Full time
UnitedHealth Group Inc.

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.


If you have a California RN license, you will have the flexibility to telecommute* as you take on some tough challenges.


Primary Responsibilities:



  • Addressing Standard and Expedited appeals cases

  • 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 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 organizational skills, must be detail oriented

  • Strong communication skills - written and verbal

  • Must be able to work with established deadlines and quick turnaround times

  • Make referrals to outside sources

  • 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.


Please review the required qualifications as posted below. To be eligible to apply and be reviewed for the position, the candidate must meet or exceed all posted required qualifications listed. Thank you for taking the time to review the job posting. We value your time and interest in the position.


Required Qualifications:



  • Current, unrestricted REGISTERED NURSE (RN) license in the State of CALIFORNIA (regardless of residency)

  • Must be able to work 8:00am - 5:00pm PST (regardless of residency)

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

  • Excellent typing skills (including spelling and grammar) with an ability to navigate a Windows based environment

  • Ability to evaluate and interpret medical records (all specialties)

  • Ability to work independently with minimal supervision

  • An attitude that fosters teamwork and supports organizational goals

  • If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders


Preferred Qualifications:



  • Appeals experience is strongly preferred

  • BSN degree or higher

  • CPT, HCPC, ICD-9 and ICD-10 coding experience is strongly preferred

  • Utilization review and/or case management experience

  • Previous experience in a telephonic or office based role

  • Creative problem-solving skills

  • Strong team player

  • Ability to optimize resources using excellent clinical judgment


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


UnitedHealthcare, part of the UnitedHealth Group family of companies, is comprised of three specialized businesses dedicated to meeting the health care benefits needs of individuals and groups; all part of something greater, but each with a specialized focus:


UnitedHealthcare Employer & Individual works with individuals, small businesses and large multi-site employers to provide innovative, affordable benefits services.


UnitedHealthcare Medicare & Retirement is focused on serving Americans over the age of 50. It is the largest business dedicated to meeting the growing health and well-being needs of aging individuals in the nation, serving one in five Medicare beneficiaries through a comprehensive and diversified array of products and services through four industry-leading businesses.


UnitedHealthcare Community & State provides high-quality, personalized, public-sector health care programs that help local government agencies improve health outcomes for millions of children and low-income and disabled individuals at an affordable cost.


Together, we're removing the barriers that keep people from receiving the kind of quality health care that makes a difference. We focus on Integrity, Compassion, Relationships, Innovation and Performance as we empower people to achieve better health and well-being


Come grow and thrive in our culture of innovation and ideas. Because there is no opportunity greater than the quest to help people live healthier lives. It's where you can do your life's best work.(sm)


Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 7 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)



  • 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.


Job Keywords: RN, Nurse, Clinical, Appeals, Case Management, Utilization Review, Utilization Management, Managed Care, CPT, ICD 9, ICD 10, UHC, Unitedhealthcare, UHG, Unitedhealth Group, Los Angeles, San Diego, San Francisco, San Bernardino, Sacramento, CA, California, Telecommute, Telecommuting, Telecommuter, Work From Home, Remote

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