Senior Clinical Administrative RN - Remote in Texas
About The Position
UnitedHealthcare is hiring a Senior Clinical Administrative RN to review member appeals and fair hearing requests. The role includes clinical and chart review, audits, denial-letter review, and collaboration with clinical and non-clinical staff to assess authorization and utilization-review determinations in preparation for Fair Hearings with the State of Texas. The RN reviews appeals and grievances to determine whether appropriate decisions were rendered. This position works with internal teams and external organizations on quality control, compliance, risk assessment, audits, and process improvement. It also requires maintaining knowledge of applicable State and Federal regulations, accrediting requirements, contracts, benefits, medical policies, and UnitedHealth Group guidelines. Texas residents may work remotely, subject to UnitedHealth Group’s Telecommuter Policy.
Requirements
- Active, unrestricted RN license in Texas.
- At least 5 years of clinical nursing experience, including utilization management, medical necessity review, care management, or a related clinical decision-making role.
- At least 3 years of experience with Appeals, Grievances, or Regulatory processes in a managed care or health plan environment.
- At least 3 years of experience with State and Federal regulations.
- At least 3 years of experience collaborating with Medical Directors, clinicians, or cross-functional partners to support clinical decisions.
- Intermediate proficiency with clinical systems and Microsoft Office, including PowerPoint, Word, Excel, and Outlook.
- High attention to detail, strong documentation abilities, and organizational skills.
Nice To Haves
- Familiarity with Texas HHSC, Medicaid managed care, or State regulatory requirements.
- Experience supporting LTSS or complex populations.
- Ability and willingness to learn Fair Hearing evidence preparation and State Fair Hearing representation; training and mentoring are provided.
- Experience presenting clinical information in a structured, professional setting.
- Demonstrated record of meeting or exceeding expectations, collaborating effectively, and meeting program goals.
- Strong written and verbal communication skills, including the ability to clearly articulate clinical rationale.
- Ability to manage time-sensitive work and meet regulatory or operational deadlines.
Responsibilities
- Work with clinical and non-clinical staff to review determinations and prepare for Fair Hearings.
- Participate in State Fair Hearings.
- Coordinate internal reviews of denial letters for compliance with State and Federal program contractual and regulatory requirements, and review procedures for efficiency and effectiveness.
- Review electronic health records to validate decision accuracy and recommend revisions, additional documentation, or other actions based on independent review.
- Perform internal quality control reviews of processes and activities and develop recommendations for improvement.
- Help coordinate an appropriate risk assessment process to identify and correct deficiencies.
- Assist with external audits and reviews conducted by clients or contracting organizations.
- Maintain knowledge of regulatory and accrediting-body requirements and serve as a compliance resource for the team.
- Interpret benefits, contracts, and medical policy.
- Review denial notices issued by the National Letter team for accuracy and compliance, and recommend improvements as needed.
- Interact effectively with other departments and maintain working relationships across the company to support goals and objectives.
- Maintain knowledge of State rules, contracts, Federal legislation and regulations, and UnitedHealth Group guidelines.
- Demonstrate flexibility, availability, and dependability, and work independently or as part of a team.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs, subject to eligibility requirements.
- Equity stock purchase, subject to eligibility requirements.
- 401(k) contribution, subject to eligibility requirements.
- Development opportunities for other roles.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
