Clinical Grievances RN - Remote in CA
About The Position
At UnitedHealthcare, the Clinical Grievances Nurse reviews incoming retrospective cases to determine whether appropriate care was provided and current cases to ensure members’ immediate needs are addressed. The role supports consumer-oriented health benefit plans and the organization’s goals of improving care quality, lowering costs, and increasing access to health care. The nurse assesses health care services provided to members, reviews cases against required clinical information, and consults with a Medical Director. The position requires understanding applicable state and federal grievance and peer review requirements and accreditation standards. The nurse documents case chronology and rationale for severity levels, descriptor codes, and any Improvement Action Plan (IAP), and facilitates telephone discussions with providers and members to gather additional clinical information. This is a remote role for someone who lives in California and can work 8 a.m.–5 p.m. Pacific time, Monday through Friday. Employees working remotely must follow UnitedHealth Group’s Telecommuter Policy. The role also involves maintaining service quality and productivity, contributing to team performance, and serving as a resource for less experienced colleagues.
Requirements
- Current, unrestricted RN license in the state of residency.
- At least 3 years of total RN experience, including recent clinical experience in an inpatient/acute setting or similar setting.
- Proficiency with Windows, instant messaging, clinical platforms, and Microsoft Word, Excel, and Outlook.
- Clinical documentation and critical-thinking skills.
- A designated workspace and access to install secure, high-speed cable or DSL internet at home.
- Reside in California and be able to work 8 a.m.–5 p.m. Pacific time.
- Adhere to UnitedHealth Group’s Telecommuter Policy when working remotely.
- Pass a drug test before beginning employment.
Nice To Haves
- Bachelor’s degree in Nursing or higher.
- Experience with Managed Care Clinical Quality Programs.
- Case management experience.
- Clinical appeals and grievances experience.
- Audit or chart-review experience.
- Experience in a telecommuting role.
- Ability to use UHG applications, including authorization applications, auto correspondence, and member and provider demographic systems.
Responsibilities
- Perform clinical assessments of health care services provided to members for appropriateness.
- Understand relevant state and federal grievance and peer review requirements and accreditation standards applicable to supported processes.
- Review cases received from the QIS non-clinical team against required clinical information, assess appropriateness, and consult with a Medical Director.
- Document case-review chronology and provide rationale for severity level, descriptor codes, and any applicable Improvement Action Plan (IAP).
- Facilitate telephone discussions with health care providers and/or members to obtain additional clinical information.
- Provide timely, quality service to members and providers while upholding UnitedHealthcare culture values.
- Act as a resource for colleagues with less experience.
- Work independently and collaborate with Medical Directors and non-clinical partners.
- Participate in a self-directed team to meet individual and team performance metrics.
- Manage and maintain quality and productivity metrics.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
