The role focuses on review of member appeals and fair hearing requests - clinical review, chart review, audits, letter review, working with clinical and non-clinical staff with varied backgrounds to review authorization, UR determinations, in preparation for a Fair Hearing with the State of Texas. The chosen
Senior Clinical Administrative RN would be responsible for reviewing appeals and grievances to determine if the appropriate decision was rendered. In providing consumer-oriented health benefit plans to millions of people; our goal is to create higher quality care, lower costs, and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.
If you are located in Texas, you will have the flexibility to telecommute* as you take on some tough challenges.
Primary Responsibilities:- Works with clinical and non-clinical staff to review determinations and prepare for Fair Hearings
- Participates in State Fair Hearings
- Coordinates internal reviews on denial letters to determine compliance with contractual and regulatory requirements of the State and Federal programs, while reviewing for efficiencies and effectiveness of procedures
- Reviews electronic Health Records to validate accuracy of decision, recommend revisions, additional documentation, or action to take based on independent review
- Performs internal Quality Control reviews on processes and activities while developing recommendations for improvement
- Serves as a catalyst for implementing an appropriate risk assessment process designed to identify and correct deficiencies
- Assists with the coordination of external audits and reviews conducted by our clients or contracting organizations
- Maintain extensive knowledge of regulatory and applicable accrediting body requirements becoming a Compliance resource for the team
- Proficient in interpreting benefits, contracts, and medical policy
- Review denial notice issued by the National Letter team to ensure accuracy and compliance, as well as providing recommendations for improvement, as needed
- Interact effectively with other departments
- Maintain knowledge of State rules, contracts, and Federal legislation/regulations as well as UHG guidelines
- Establish and maintain good working relationships throughout the company to support goals and objectives
- Demonstrate flexibility, availability, and dependability to conform to position responsibilities
- Ability to work independently or in a team environment
- The applicant should possess a high attention to detail, exceptional documentation abilities, and organizational skills
You9ll 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.
Required Qualifications:- Active, unrestricted RN license in the state of Texas
- 5+ years of clinical nursing experience, including utilization management, medical necessity review, care management, or a related clinical decision - making role
- 3+ years of experience with exposure to Appeals, Grievances, or Regulatory processes in a managed care or health plan environment
- 3+ years of experience with knowledge of State and Federal Regulations
- 3+ years of experience collaborating with Medical Directors, clinicians, or cross-functional partners to support clinical decisions
- Intermediate level of proficiency with clinical systems and Microsoft Office suite (PowerPoint, Word, Excel, and Outlook)
Preferred Qualifications:- Familiarity with Texas HHSC, Medicaid managed care, or state regulatory requirements
- Experience supporting LTSS or complex populations
- Ability and willingness to learn Fair Hearing evidence preparation and State Fair Hearing representation, with training and mentoring provided
- Experience presenting clinical information in a structured, professional setting
- Demonstrated track record of meeting or exceeding expectations, functional collaboration, and meeting program goals
- Strong written and verbal communication skills, with the ability to clearly articulate clinical rationale
- Proven ability to manage time-sensitive work and meet regulatory or operational deadlines
*All Telecommuters will be required to adhere to UnitedHealth Group9s 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, you9ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.
