Manager of Clinical Validation, Audit Support - Remote

UnitedHealth Group•Clarksville, TN

1d•$91,700 - $163,700•Remote

About The Position

This position provides clinical oversight and quality review of 1) Appeal submissions prepared by review partners for escalation to the CMS Independent Review Entity (IRE) on behalf of UHC Payment Integrity, 2) Review partner oversight of Facility DRG audits for coding and clinical accuracy and consistency 3) Review partner oversight of Home Health, Skilled Nursing claims audits, and 4) Oversight of cost outlier audits. The role ensures that clinical arguments are accurate, complete, and defensible, with medical record evidence, coding validation, and policy references clearly articulated and aligned with CMS standards. Responsibilities include reviewing vendor-prepared appeal determinations for clinical validity, clarity, structure, and consistency; identifying gaps or risk areas prior to submission; and collaborating with internal stakeholders to mitigate regulatory and STAR rating risk. The position also supports continuous quality improvement by monitoring IRE outcomes, identifying trends, and driving corrective actions across review partners. This position reports to the Chief Medical Officer (CMO) for Payment Integrity You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Current, unrestricted Registered Nurse (RN) license
Certified Professional Coder (CPC) or equivalent nationally recognized coding certification
4+ years of experience performing clinical denial review, appeal preparation, or denial rebuttal writing on behalf of a payer, with demonstrated responsibility for appeal quality and regulatory defensibility
1+ years of experience with Inpatient facility DRG coding, auditing, or clinical validation review supporting appeals or payment integrity activities
Demonstrated expertise applying CMS regulations, coverage determinations, clinical validation principles, and coding standards (ICD 10 CM/PCS, Official Coding Guidelines)
Advanced proficiency with EMR systems, Microsoft Office tools, (including Word, Excel, Outlook, PowerPoint, CoPilot), and AI/ML to support clinical review, documentation, and reporting

Nice To Haves

Certification in Clinical Documentation Improvement (CCDS or CDIP)
Certified Inpatient Coder (CIC) credential
Experience supporting CMS Independent Review Entity (IRE) submissions, UCRO style vendor oversight, or second level appeal quality review
Experience with Home Health Prospective Payment System (HH PPS) reviews, including Patient Driven Groupings Model (PDGM) validation
Experience with Itemized Bill Reviews and Cost Outlier analysis
Proven involvement in quality improvement, trend analysis, or audit support initiatives related to appeals, clinical validation, or payment integrity

Responsibilities

Provide primary clinical and coding quality oversight of review partner appeal submissions prior to escalation to the CMS Independent Review Entity (IRE), ensuring compliance with UHC standards and regulatory timelines
Review vendor prepared appeals for clinical validity, coding accuracy, clarity, structure, and consistency, confirming that medical record evidence and policy citations fully support the appeal position
Evaluate appeals against authoritative clinical, coding, and administrative references, including CMS coverage determinations, Clinical Validation Guidelines (CVA), UHC reimbursement policies, and ICD 10 CM/PCS coding standards
Identify gaps, inconsistencies, or regulatory risk in submissions and direct corrective action, revision, or escalation to ensure defensible IRE submissions
Triage complex cases requiring CMO involvement and review outcomes of escalated clinical determinations
Render nurse or analyst level determinations for administrative aspects of appeals based on clinical documentation, policy interpretation, and coding guidance
Provide clinical and coding oversight of Home Health Prospective Payment System (HH PPS) reviews and cost outlier audit determinations
Perform second level clinical quality review of cases overturned by the CMS Independent Review Entity (IRE), identifying root causes, documentation deficiencies, and recurring risk patterns
Monitor IRE outcomes and appeal trends to support continuous clinical quality improvement and reduce repeat deficiencies across review partners
Collaborate with Payment Integrity, Appeals & Grievances, vendors, and internal stakeholders to mitigate regulatory, compliance, and CMS STAR rating risk related to Non Par appeals
Demonstrate solid clinical judgment and written communication skills, clearly articulating concise, evidence based clinical and coding rationale in appeal documentation
Coordinate with cross enterprise teams (Optum, vendors, Operations, Network partners, and Payment Integrity leadership) to support priorities impacting submissions
Summarize and communicate proposed process or technical changes, including documentation of needs, risks, impacts, and expected outcomes, to support stakeholder alignment
Support planning, execution, and monitoring of process improvement initiatives related to clinical oversight and IRE submission quality
Identify downstream operational impacts of process changes across Payment Integrity workstreams and recommend adjustments as needed
Track and communicate changing requirements, priorities, and project status throughout the project lifecycle
Contribute to the development and maintenance of policies, procedures, training materials, and job aids supporting UCRO and IRE processes
Foster effective collaboration across matrixed teams by building consensus and supporting resolution of issues
Apply diplomacy and sound judgment when navigating competing priorities or stakeholder concerns