At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us and start doing your life's best work.(sm)

The Clinical Appeals RN is responsible for providing expertise in clinical appeals and grievances (analyzing, reviewing and evaluating appeals and grievances), and acting as a Clinical Interface Liaison (clinical problem solver with facilities, providers, carriers, resolution of issues concerning members, benefits, program definition and clarification).

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

Primary Responsibilities:

• Review medical records and verify if the requested service meets criteria


• Review pre-service appeals for clinical eligibility for coverage as prescribed by the Plan benefits


• Review and interpret Plan language


• Coordinate reviews with the Medical Director


• Utilize clinical guidelines and criteria


• Accurately documenting determinations


• Adherence to all confidentiality regulations and agreements


• Hours M-F 8a-5p with alternating Saturdays


• Comfortable working mandatory overtime

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:

• Active, unrestricted RN license in state of residence


• 2+ years of clinical experience as an RN, including in an acute, inpatient hospital setting


• Proficiency in Microsoft Office, Word, Outlook, and Internet applications


• Available M-F, as well as alternating Saturdays

Preferred Qualifications:

• Bachelor of Science in Nursing


• 1+ years of experience using MCG and/or Medicare criteria


• 1+ years of Utilization Management, pre-authorization, concurrent review or appeals experience


• Appeals experience


• Excellent communication, interpersonal, problem-solving and analytical skills

Careers with UnitedHealthcare. Work with a Fortune 5 organization that’s serving millions of people as we transform health care with bold ideas. Bring your energy for driving change for the better. Help us improve health access and outcomes for everyone, as we work to advance health equity, connecting people with the care they need to feel their best. As an industry leader, our commitment to improving lives is second to none.

California, Colorado, Connecticut, Nevada, New York, Rhode Island, or Washington Residents Only: The hourly range for California, Colorado, Connecticut, Nevada, New York, Rhode Island or Washington residents is $27.07 to $53.08. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

•All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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.

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.