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Senior Clinical Appeals RN – Sacramento, CA or Phoenix, AZ - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Sacramento, CA Sacramento, California |
About this job
Health care isn't just changing. It's growing more complex every day. ICD10 replaces ICD9. Affordable Care adds new challenges and financial constraints. Where does it all lead? Hospitals and health care organizations continue to adapt, and we are vital part of their evolution. And that's what fueled these exciting new opportunities.
Who are we? Optum360. We're a dynamic new partnership formed by Dignity Health and Optum to combine our unique expertise. As part of the growing family of UnitedHealth Group, we'll leverage our compassion, our talent, our resources and experience to bring financial clarity
and a full suite of revenue management services to health care providers nationwide.
and a full suite of revenue management services to health care providers nationwide.
If you're looking for a better place to use your passion, your ideas and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work. (SM)
This is a 40 hour, Monday-Friday, non exempt position. This position is not hospital based, and is located in the Clinical Appeals office in Rancho Cordova or Phoenix, AZ.
Responsibilities:
- Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence based medicine, community and national medical management standards and protocols.
- Performs review of all claims denied for clinical related attributions, including but not limited to: level of care, no authorization, medical necessity, non-covered benefits and denied days.
- Assures appropriate action is taken within appeal time frames to address clinical denial.
- Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRGs, Outlier Payments, and Stop Loss.
- Collaborates with Physician Advisors in identified clinical denials requiring escalation.
- Communicates identified denial trends and patterns to Clinical Appeal Unit Manager.
- Maintains clinical expertise and trends in healthcare, reimbursement methodologies and UM specialty areas by participating in professional organizations, seminars and educational programs.
- Provides expert application of evidence-based medical necessity review tool.
- Utilizes multiple tools (MIDAS+, Veracity, Artiva, etc.) in accurate tracking of clinical denial data. Works collaboratively to review, evaluate and improve the denial appeal process and establish a system-wide uniform process
- Participates in federal and state audit activity from appeal to legal proceedings (if needed) and maintains documentation of activity.
Requirements
Qualifications:
- Current, unrestricted, RN license in CA or AZ
- 3 years clinical RN experience
- Proficient in computer use and Microsoft applications – must be able to pick up on programs easily
- Must be able to adapt well to change
- Excellent written and verbal communication skills
Preferred Qualifications:
- Knowledge of CMS regulations
- Experience in Denial Management, Utilization Review, Case Management or related experience
- Experience preparing appeals for clinical denials
- Expertise with InterQual and/or Milliman
- BSN degree
- Current working knowledge of discharge planning, utilization management, case management or performance improvement, and managed care reimbursement
What can YOU do with the right information? At Optum360, the possibilities and the impact are limitless. No matter what your role is at Optum360, you'll be empowered to ask more questions, develop better solutions and help make the health care system greater than ever. It's always fresh. It's always exciting. And it's never been more important.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
Keywords: RN, Appeals, Case Managment, Sacramento, Phoenix, UM, Registered Nurse
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