Senior Clinical Administrative RN - Remote in Texas

UnitedHealth Group•Houston, TX

9d•$60,200 - $107,400•Remote

About The Position

The Senior Clinical Administrative RN reviews member appeals and fair hearing requests, including clinical records, charts, audits, and denial letters. The role evaluates whether appropriate decisions were made and works with clinical and non-clinical staff to review authorizations and utilization review determinations in preparation for State of Texas Fair Hearings. The position also supports quality control, regulatory compliance, risk assessment, and external audits, while helping improve processes and documentation. This remote position is available to applicants located in Texas; telecommuters must follow UnitedHealth Group’s Telecommuter Policy.

Requirements

Active, unrestricted RN license in the state of 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 exposure to appeals, grievances, or regulatory processes in a managed care or health plan environment.
At least 3 years of experience with knowledge of 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, exceptional documentation abilities, and organizational skills.
Adherence to UnitedHealth Group’s Telecommuter Policy for telecommuters.
Pass a drug test before beginning employment.

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 track 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.
Proven 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 requirements and assess procedural efficiency and effectiveness.
Review electronic health records to validate decisions and recommend revisions, additional documentation, or other actions based on independent review.
Conduct internal quality control reviews and develop recommendations for process improvement.
Support implementation of an appropriate risk assessment process to identify and correct deficiencies.
Assist with coordinating 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 UHG guidelines.
Demonstrate flexibility, availability, and dependability in meeting position responsibilities.
Work independently or as part of a team.
Review appeals and grievances to determine whether the appropriate decision was rendered.