Senior Clinical Appeals RN

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 Sr 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 work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

• 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.

Required Qualifications

• Unrestricted RN (registered nurse) license in your state of residence
• CCS or CIC certification or willing to obtain within 6 months of hire
• 2+ years of 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)
• 2+ years of 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), or CIC (certified inpatient coder)
• 3+ years of MS DRG/APR DRG coding experience in a hospital environment with knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
• 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 employees working remotely 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 $35 - $63 per hour based on full-time employment. We comply with all minimum wage laws as applicable.