Senior Clinical Appeals RN

UnitedHealth Group • Plymouth, MN

83d • $34 - $61 • Remote

About The Position

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. The Senior Clinical Appeals RN utilizes subject matter expertise in MS-DRG and APR-DRG auditing to review and provide response to appeals. By partnering with the original auditor, review medical records, and other information to author a rebuttal or agreement with the facility. This person will be instrumental in providing coaching and education to our remote DRG Validation Specialists utilizing core coding and clinical information. We are seeking self-motivated, solution oriented and skilled problem solvers who provide written documentation under tight deadlines. As a Senior Clinical Appeals RN, you will derive key insights from the appeals and provide guidance and direction to fellow auditors across our business.

Requirements

• Associate's degree (or higher)
• Unrestricted RN (Registered Nurse) license in your state of residence
• CCS or CIC or ability to obtain certification within 6 months of hire
• 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
• Advanced level of proficiency with ICD -10-CM coding including knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs) and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
• Advanced level of proficiency with ICD-10-PCS coding including knowledge of the structural components of PCS including but not limited to, selection of appropriate body systems, root operations, body parts, approaches, devices and qualifiers

Nice To Haves

• Managed care experience
• Healthcare claims experience
• Investigation and/or auditing experience
• Knowledge of health insurance business, industry terminology and regulatory guidelines
• Proficiency with MS Excel including the ability to create/edit spreadsheets and use sort/filter function
• An existing coding certification, such as RHIT (registered health information technician), RHIA (registered health information administrator), CDIP (certified documentation improvement practitioner), CCS (certified coding specialist), CIC (certified inpatient coder) or CPC (certified professional coder)

Responsibilities

• Analyze scope and resolution of DRG Appeals
• Respond to Level one, two or higher appeals
• Perform complex conceptual analyses
• Identify risk factors, comorbidities, and adverse events, to determine if overpayment or claim adjustment is needed
• Review governmental regulations and payer protocols and / or medical policy to recommend appropriate actions
• Research and prepare written appeals
• Exercise clinical and/or coding judgment and experience
• Collaborate with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims
• Navigate through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel
• Serve as a key resource on complex and / or critical issues and help develop innovative solutions
• Define and document / communicate business requirements

Benefits

• $10,000 SIGN ON BONUS FOR EXTERNAL APPLICANTS
• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree