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Manager of Clinical Validation, Audit Support - Remote Nationwide job in Atlanta at UnitedHealth Group

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Manager of Clinical Validation, Audit Support - Remote Nationwide at UnitedHealth Group

Manager of Clinical Validation, Audit Support - Remote Nationwide

UnitedHealth Group Work From Home Full Time

Careers at UnitedHealth Group. We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these select few, we offer the global reach, resources and can-do culture of a Fortune 7 company. We provide an environment where you're empowered to be your best. We encourage you to take risks. And we offer a world of rewards and benefits for performance. We believe the most important is the opportunity to do your life's best work.(sm)

Positions in this function are responsible for conducting reviews and responding to insurance denials for facility appeals. Writes concise, factual letters and provides medical record documentation to support appeal. Effectively communicates verbally with external and internal customers to ensure argument for appeal is clearly presented. Responsible for the denials process, including subsequent appeal to health insurance. Responsible for continuous process improvement of appeal program. Support Payment Integrity on provider and regulatory escalations.

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

Primary Responsibilities:

  • Assures appropriate action is taken within appeal time frames to address clinical denial
  • Collaborates with other departments/resources/entities as applicable to ensure the most optimal appeal outcome
  • Determine whether cases meet applicable clinical and/or administrative criteria, as defined by relevant references/resources (e.g., MCG, reimbursement policies, CDG, coding manuals)
  • Assess which cases warrant assignment to Medical Directors, forward as needed, and review the outcome of their determination
  • Make determinations for administrative cases at the nurse level about whether the appeal should be approved or denied, based on available analyses/research of applicable information
  • Take appropriate steps based on case determination by the Medical Director or nurse (e.g., denial upheld, overturned, dismissed, pended for additional action)
  • Utilizes appropriate applications to accurately track clinical denial data; participates in the development and implementation of a system-wide process for appeals
  • Reviews and has knowledge of applicable Medicare, Medicaid, or Commercial determinations and policies, including Local Coverage Determinations, National Coverage Determinations, Policy Bulletins, etc.
  • Assists with continuous quality improvement of the established appeals process
  • Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, and discharge disposition, in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance
  • Document final determination of appeals or grievances using appropriate platforms, templates, communication processes, etc. (e.g., ETS, email)
  • Communicate determinations to relevant stakeholders, as applicable (e.g., appellants, providers, vendors)
  • On a monthly basis presents identified denial trends and patterns and creates education on root cases and preventable measures
  • Responsible for second level review of all overturned cases from CMS Independent Review Entity (IRE)
  • Support the Medical Director as needed with peer-to-peer discussions.
  • Provide clinical and strategic input when participating in organizational committees, projects, and task forces.
  • Support the Payment Integrity team in their interactions with providers to explain clinical validation audit findings and the application of clinical criteria
  • Clinical discernment/critical thinking skill to identify what defines the patient encounter
  • Excellent written communication skills with the ability to clearly articulate ideas and arguments in a letter
  • Strong verbal communication and organization skills

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:

  • Undergraduate degree or High School Diploma/GED with 7 years of experience preparing appeals for clinical denials or writing clinical denials on behalf of payers
  • Current, unrestricted RN license
  • 3+ years of experience preparing appeals for clinical denials or writing clinical denials on behalf of payers
  • 2+ years of experience working with Inpatient facility DRG experience (coding or auditing)
  • Advanced proficiency with EMR and Microsoft Suite; Word, Excel, Outlook and PowerPoint

Preferred Qualifications:

  • DRG certification
  • CPC, CCS or equivalent Coding Certification
  • Certification in Clinical Documentation Improvement (CCDS or CDIP)
  • 3+ years of appeals, coding, or CDI experience

UnitedHealth Group is an essential business. The health and safety of our team members is our highest priority, so we are taking a science driven approach to slowly welcome and transition some of our workforce back to the office with many safety protocols in place. We continue to monitor and assess before we confirm the return of each wave, paying specific attention to geography-specific trends. At this time, 90% of our non-clinical workforce transitioned to a work at home (remote) status.  We have taken steps to ensure the safety of our 325,000 team members and their families, providing them with resources and support as they continue to serve the members, patients and customers who depend on us.

You can learn more about all we are doing to fight COVID-19 and support impacted communities: [ Link removed ] - Click here to apply to Manager of Clinical Validation, Audit Support - Remote Nationwide[ Link removed ] - Click here to apply to Manager of Clinical Validation, Audit Support - Remote Nationwide

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

Colorado Residents Only: The salary range for Colorado residents is $79,700 to $142,600. Pay is based on several factors including but not limited to education, work experience, certifications, etc. As of the date of this posting, In addition to your salary,  UHG offers the following benefits for this position, subject to applicable eligibility requirements: Health, dental, and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term disability insurance, and long-term disability insurance; business travel accident insurance; Employee Assistance Program; PTO; and employee-paid critical illness and accident insurance.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: #RPO, work at home, WFH, WAH, work from home, UHC, UnitedHealth Group


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