Utilization Management & Clinical Validation RN

The Utilization Management & Clinical Validation RN will accurately and efficiently review and extract pertinent case details from patient medical records; and craft strongly defensible appeal letters per process instructions and the department's/company's guidance. They will have a working knowledge encoder use and selecting appropriate, supportable appeal arguments from evidence-based, peer reviewed medical literature as provided as well as interpreting and utilizing ICD 9 and 10, CM and PCS, CPT coding system, and HCPCS guidelines. They will recommend changes to coding which will retain, lessen, or increase financial impact when analysis of chart indicates opportunities. The Appeals nurse will perform their job functions, adhering to both Optum and OPAS policies and procedures, which include but are not limited to the following:

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

• Adheres to approved schedule and arrives to work timely
• Maintains accurate accounts of time off in both Verint and HR Direct as per guidelines, and follows directives for time off, schedule changes, etc.
• Follows directive of composing appeal letters to include appropriate data extraction, construction of well-written appeals letters with proper grammar, utilization of appeal tools including pre-constructed templates, and inclusion of appropriate medical literature references
• Use and fluency of encoders, coding clinics, ICD-9 and 10 guidelines, CM and PCS, CPT coding system and HCPCS guidelines
• Working knowledge of Word
• Effective communication skills
• Excellent typing skills with a minimum of 45/min speed
• Adheres to company policies and procedures as well as policies, procedures, and laws
• Understands and complies with HIPAA confidentiality requirements
• Support and promote OPAS, Optum, and the enterprise goals and mission
• Build relationships across Optum, OPAS, OGA and our clients
• Collaborate with peers to assure continuity of communication and execution of deliverables as needed
• Adheres to quality and productivity expectations
• Participate in and contribute to meetings as appropriate
• Maintains organization on the team and ensures everyone conducts themselves professionally
• Remains up to date with all learning modules, competencies, and state required licenses
• Performs other related duties, tasks, and processes as required by leadership
• Ability to establish priorities, be self-motivated, work independently, and follow instructions with supervision and structure
• Positive attitude and the ability to function as a collaborative team member

Required Qualifications

• Associates degree or higher
• Unrestricted RN license required in state of residence
• 3+ years of Clinical experience in ED/Telemetry/Critical Care
• 2+ years of experience in clinical validation appeals

Preferred Qualifications

• Pre-authorization experience
• License certified coder
• Utilization Management experience
• Case Management experience
• Knowledge of Milliman Criteria
• Certified Case Manager (CCM)

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

The salary for this role will range from $60,200 to $107,400 annually based on full-time employment.