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  • Boston, MA

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Clinical Appeals, RN - Telecommute - Boston, MA

UnitedHealth Group • Boston, MA

Posted 6 days ago

Job Snapshot

Full-Time
Healthcare - Health Services
Health Care, Nurse

Job Description


There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)


 
***This is a telecommuter position, but it does require local travel to office locations throughout the area. If you are located in the Boston area you will have the flexibility to telecommute* as you take on some tough challenges***



Primary Responsibilities:



Main responsibilities are to perform / support clinical appeals with additional responsibilities to include:



  • Attending appeals hearings on a case to case basis

  • Determines medical appropriateness of provider services following evaluation of medical

  • Responsible for performing prior authorization review of services that require notification, using applicable benefit plan documents, evidence - based medical policy and state specific recognized clinical guidelines and criteria guidelines and benefit determination

  • Interacts with providers to obtain clinical information to support the appeals process and prior authorization determinations and provide support for their questions

  • Evaluate applicability of community resources/government programs / LTSS provider services to member needs

  • Navigate relevant computer systems to identify internal and external resources


Required Qualifications:




  • Active, unrestricted RN license in the state of MA

  • 5+ years of experience in clinical nursing, PA / UM or working with individuals receiving LTSS services

  • Experience in Appeals and / or Utilization Management

  • Medicaid Experience

  • Ability to collaborate with stakeholders

  • Ability to create, edit, save and send documents utilizing Microsoft Word. Ability to navigate a Windows environment

Preferred Qualifications:




  • Undergraduate degree

  • Prior Authorization experience

  • Ability to interpret benefits and /or apply clinical / LTSS guidelines

  • Chart Review

  • Case Management experience

  • Certified Case Manager (CCM)

  • Experience working with the LTSS population

  • Managed Care Experience

Already Fortune 6, we are totally focused on innovation and change. We work a little harder. We aim a little higher. We expect more from ourselves and each other. And at the end of the day, we're doing a lot of good.



Through our family of businesses and a lot of inspired individuals, we're building a high - performance health care system that works better for more people in more ways than ever. Now we're looking to reinforce our team with people who are decisive, brilliant - and built for speed.



Come to UnitedHealth Group, and share your ideas and your passion for doing more. We have roles that will fit your skills and knowledge. We have diverse opportunities that will fit your dreams.



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



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: registered nurse, RN, appeals, denials, case manager, UM, UR, PA, prior authorization, pre authorization, utilization management, Utilization review, chart review, quality review, Milliman, CCM, LTSS, long term care, managed care, Medicaid, Boston, Chelsea, Tewksbury, Quincy, Taunton, Springfield, MA, Massachusetts

Job ID: 2551_766546
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