Registered Nurse, Appeals Drafting Service - Remote

UnitedHealth Group•Jeffersonville, IN

10h•Remote

About The Position

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. This role is within UnitedHealth Group, specifically Optum, where you will utilize your operations experience to support multiple internal teams, providers, and patients. The Specialty Appeals Registered Nurse fills an integral role in drafting and submitting appeals for specialty patients with acute and chronic disease states. In this position, you will be responsible for preparing appeal letters, obtaining support documents, following up on prior authorization outcomes, and addressing issues and concerns from other departments. The company fosters a culture guided by inclusion, offers comprehensive benefits, and provides career development opportunities.

Requirements

Active, Registered Nurse License
Willingness to obtain Case Management Certification (CCM) once eligible
2+ years of clinical experience as a Registered Nurse
1+ years of experience working with prior authorization, pre-certification, utilization review, and / or appeals experience
Understanding of clinical documentation from physician offices
Proficiency with MS Word, Excel, SharePoint
Proven ability to work independently (At home or office)

Nice To Haves

Bachelor’s degree
RN licenses in multiple states (outside of compact states)
Case Management Certification (CCM)
PBM and / or Managed Care experience
Prior Authorization/Appeal Experience
Knowledge of healthcare insurance plans, denials, and appeal procedures
Advanced computer skills; Experience in a paperless role

Responsibilities

Drafting and submitting appeals for specialty patients with acute and chronic disease states
Preparing appeal letters for submission
Obtaining support documents
Following up on prior authorization outcomes
Addressing issues and handling concerns from other corresponding departments
Communicate with providers, patients, and pharmacy staff to obtain necessary clinical documentation, prior authorizations, and appeal letters
Facilitate appeals process between the patient, physician, and insurance company by requesting denial information and facilitates obtaining the denial letter from the insurance, patient or physician
Composes clinical appeals letters based off of specific denial reason and patients clinical presentation
Ensures all clinical information and documentation are obtained prior to appeal submission
Accessing multiple Optum resources to check PA, insurance and appeal status and benefits
Utilization of and proficiency in multiple internal processing systems for record keeping and tracking of letter determinations
Interpret and utilize clinical documentation from providers, and different pharmacy/computer systems
Utilizing multiple platforms, researching clinical studies for points of argument for appeals
Write and return assigned appeals to providers
Utilization of and proficiency in multiple internal processing systems for record keeping and tracking of determinations
Assign appeal requests to coworkers as needed (rotating schedule)
Perform other related duties as assigned