IBR Clinical Appeals Analyst - Remote

UnitedHealth Group•Plymouth, MN

8h•$35 - $63•Remote

About The Position

The Internal Quality Analyst for Itemized Bill Review (IBR) Clinical Appeals is an experienced RN who performs clinical appeals review responsibilities while also supporting internal quality, process documentation, training, onboarding, and implementation activities. This role analyzes and responds to client and/or hospital claim review appeal inquiries, completes medical record review, evaluates data, and prepares written response resolutions for clients and the business unit. In addition, this role serves as a team resource for focused audits, second-set-of-eyes reviews, process updates, new client implementations, and process improvement opportunities that support metric performance, SLA maintenance, and overall quality improvement. This position is full-time, Monday - Friday. Employees are required to work our normal business hours of 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Undergraduate nursing degree
Unrestricted RN (registered nurse) license
2+ years of appeals experience (coding or auditing)
Experience with CPT-4 coding, NCCI edit resolution and appropriate modifier use
Experience supporting internal quality functions, including focused audits, second-set-of-eyes reviews, quality monitoring, and/or feedback support
Experience supporting process documentation, workflow updates, standard work, job aids, training materials, or implementation-related resources
Experience training, onboarding, mentoring, or serving as a team resource for new hires, peers, or business partners
Experience participating in process improvement activities, team initiatives, client implementations, or projects supporting SLA, quality, and metric performance
Advanced experience with regulations, compliance and composing professional appeal responses
Advanced experience with ICD10 CM coding and ICD 10 PCS coding
Willing or ability to work our normal business hours of 8:00am - 5:00pm
Proven ability to keep all company sensitive documents secure (if applicable)
Have a dedicated work area established that is separated from other living areas and provides information privacy
Live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

Nice To Haves

Experience as a Team Lead or Subject Matter Expert (SME)
Clinical claim review experience
Managed care experience
Investigation and/or auditing experience
Advanced experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry
Knowledge of health insurance business, industry terminology, and regulatory guidelines

Responsibilities

Analyze scope and resolution of IBR Clinical Appeals, including medical record review, claim review data analysis, and preparation of written appeal responses
Respond to level one, level two, or higher-level appeals using clinical judgment, coding knowledge, regulatory guidance, payer protocols, and medical policy
Perform complex conceptual analyses to identify risk factors, comorbidities, adverse events, overpayment opportunities, and claim adjustment needs
Complete internal quality functions, including second-set-of-eyes reviews, focused audits, targeted quality checks, and feedback support to promote accuracy and consistency
Support training and onboarding of new hires through job aids, process demonstrations, case review support, and ongoing knowledge reinforcement
Maintain, update, and communicate process documentation, standard work, workflows, and team resources to support operational alignment
Participate in new client implementations by supporting process readiness, training needs, documentation updates, workflow validation, and post-implementation quality monitoring
Partner with auditors, quality, operations, and leadership teams to review impacted claims, identify trends, resolve issues, and recommend process improvements
Serve as a key team resource on complex and/or critical issues, team initiatives, projects, and process improvement opportunities
Define, document, and communicate business requirements, process changes, quality expectations, and implementation-related updates
Navigate web-based portals and independently use online tools and resources, including Microsoft Word, Adobe, Excel, and other business systems, to complete appeals, quality, training, and documentation activities