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Senior Clinical Appeals RN – National Remote ID-14557

May 9, 2025

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.

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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.

Primary Responsibilities:

Analyze the 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 teams 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.

Required Qualifications:

Associates Degree (or higher)
Unrestricted RN (registered nurse) license in your state of residence
CCS or CIC or the ability obtain certification within 6 months of hire
3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
Advanced level of proficiency with ICD -10-CM coding including but not limited to knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
Advanced level of proficiency with ICD-10-PCS coding including but not limited to knowledge of the structural components of PCS including but not limited to; selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers

Preferred Qualifications:

An existing coding certification, such as RHIT (registered health information technician), RHIA (registered health information administrator), CDIP (certified documentation improvement practitioner), CCS (certified coding specialist), CIC (certified inpatient coder), or CPC (certified professional coder)
Managed care experience
Healthcare claims experience
Investigation and/or auditing experience
Knowledge of health insurance business, industry terminology, and regulatory guidelines
Proficiency with MS Excel, including the ability to create/edit spreadsheets and use sort/filter function

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

The salary range for this role is $34.42 to $67.60 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.

#RPO, #GREEN

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DISCLAIMER

Senior Clinical Appeals RN – National Remote ID-14557

Other Jobs You May Be Interested In

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

5. HOW DO YOU PROCESS INFORMATION?

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

8. HOW TO PRIORITIZE WORK?

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?