Clinical Grievances RN - Remote in CA
About The Position
As a Clinical Grievances Nurse, you review retrospective cases to determine whether appropriate care was provided and current cases to ensure members’ immediate needs are being addressed. The role supports consumer-oriented health benefit plans and aims to improve care quality, reduce costs, and increase access to health care. You will work remotely from California during Pacific time business hours, Monday through Friday, 8 a.m. to 5 p.m. You will assess the appropriateness of health care services, review grievance cases against clinical information, consult with Medical Directors, document case findings and rationale, and communicate with providers and members to obtain additional clinical information. You will also support team performance and quality metrics, provide guidance to less-experienced colleagues, and deliver timely service while upholding UnitedHealthcare’s values. Remote employees must comply with UnitedHealth Group’s Telecommuter Policy.
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 or similar setting.
- Proficiency with Windows, instant messaging, clinical platforms, and Microsoft Word, Excel, and Outlook.
- Demonstrated 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 work 8 a.m. to 5 p.m. Pacific time.
- Adhere to UnitedHealth Group’s Telecommuter Policy if 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, as well as applicable accreditation standards.
- 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 less-experienced colleagues.
- Work independently and collaboratively with Medical Directors and non-clinical partners.
- Contribute as a member of 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
