Clinical Appeals RN

%3Cp class=%22MsoNormal%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EOptum 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 makes an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start%26nbsp;%3Cstrong%3ECaring. Connecting. Growing together.%3C/strong%3E%3C/span%3E%3C/p%3E%3Cp class=%22MsoNormal%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EThe%26nbsp;%3Cstrong%3EClinical Appeals RN%3C/strong%3E%26nbsp;is responsible for attending appeal hearings, defending MassHealth prior authorization decisions, and performing pre-service/prior authorization clinical coverage review of services. Works closely with managers and peers.%3C/span%3E%3C/p%3E%3Cp class=%22MsoNormal%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EIf you currently reside in the state of%26nbsp;%3Cstrong%3EMassachusetts%3C/strong%3E, you’ll enjoy the flexibility to telecommute* as you take on some tough challenges.%3C/span%3E%3C/p%3E%3Cp class=%22MsoNormal%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3E%3Cstrong%3EPrimary Responsibilities:%3C/strong%3E%3C/span%3E%3C/p%3E%3Cul style=%22margin-top:0in;%22 type=%22disc%22%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3ERepresent MassHealth at appeal hearings%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EDefend MassHealth prior authorization decisions by utilizing program specific regulations, medical necessity guidelines, standards of care and best practices%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3ERepresents the MA MLTSS program in a positive, solution-focused manner that embodies our corporate values: Integrity, Compassion, Relationships, Innovation and Performance%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EDetermine the appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EIdentify solutions to non-standard requests and problems%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EParticipate in regular meetings to collaborate with supporting leadership and team to ensure operational efficiency%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EAssures performance adheres with established quality standards, evidenced based practice guidelines and departmental benchmarks and workflows%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EAct as a resource for others; provide explanations and information on difficult issues%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l0 level1 lfo1;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EMinimum 10% travel within the state of MA%3C/span%3E%3C/li%3E%3C/ul%3E%3Cp class=%22MsoNormal%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3E%3Cstrong%3EWhat are the reasons to consider working for UnitedHealth Group?%26nbsp;%26nbsp; Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:%3C/strong%3E%3C/span%3E%3C/p%3E%3Cul style=%22margin-top:0in;%22 type=%22disc%22%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EPaid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EMedical Plan options along with participation in a Health Spending Account or a Health Saving account%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EDental, Vision, Life%26amp; AD%26amp;D Insurance along with Short-term disability and Long-Term Disability coverage%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3E401(k) Savings Plan, Employee Stock Purchase Plan%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EEducation Reimbursement%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EEmployee Discounts%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EEmployee Assistance Program%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EEmployee Referral Bonus Program%3C/span%3E%3C/li%3E%3Cli class=%22MsoNormal%22 style=%22mso-list:l1 level1 lfo2;tab-stops:list .5in;%22%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EVoluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)%3C/span%3E%3C/li%3E%3C/ul%3E%3Cp%3E%3Cspan style=%22color:black;font-family:Tahoma, Geneva, sans-serif;font-size:10px;%22%3EYou’ll 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.%3C/span%3E%3C/p%3E

Required Qualifications:

• Associate's degree in Nursing 
• Unrestricted RN license required in the state of Massachusetts
• 3+ years of Managed Care and/or clinical experience
• Designated workspace and access to install secure high-speed internet via cable or DSL in home
• Reside in the state of Massachusetts

Preferred Qualifications:

• Prior-Authorization experience
• Utilization Management experience
• Appeals Experience
• Medicare/Medicaid experience preferred
• Proficient with Microsoft Office programs, including Word, Excel, PowerPoint
• Excellent communications skills, including the ability to write clearly, succinctly and in a manner that appeals to a wide audience
• Excellent time management, organizational, and prioritization skills with ability to balance multiple priorities

*All Telecommuters 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 $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable. 

    

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