IBR Clinical Appeals Reviewer - Remote

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 inclusion, talented peers, comprehensive benefits and career development opportunities.

Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Itemized Bill Review (I ) Clinical Appeals Reviewer will analyze and respond to client and/or hospital claim review appeal inquiries. Handles medical record review, analyzes data, and completes the response resolution for clients and the business unit. Must utilize expertise in auditing to review and provide response to appeals. We are seeking self‑motivated, solution‑oriented and skilled problem solver who provides clinical reviews with written documentation under tight deadlines.

This position is full‑time, Monday – Friday. Employees are required to work our normal business hours of 8:00 am – 5:00 pm. It may be necessary, given the business need, to work occasional overtime or weekends.

You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

• Analyze scope and resolution of I  Appeals
• Respond to Level one, two or higher appeals
• Perform complex conceptual analyses
• Identify risk factors, comorbidities, and adverse events, to determine if over payment 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 understand and review medical records pertaining to impacted claims
• Navigate through web‑based portals and independently utilize 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

• Undergraduate nursing degree
• Unrestricted RN (registered nurse) license
• Minimum two years appeals experience (coding or auditing)
• Experience with CPT‑4 coding, NCCI edit resolution and appropriate modifier use
• Advanced experience with regulations, compliance and composing professional appeal responses
• Advanced experience with ICD
  10‑CM coding and ICD
  10‑PCS coding
• Willing or ability to work our normal business hours of 8:00 am – 5:00 pm

• Advanced experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry
• Clinical claim review experience
• Managed care experience
• Investigation and/or auditing experience
• Knowledge of health insurance business, industry terminology, and regulatory guidelines

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Must live in a location that can receive a United Health Group approved high‑speed internet connection or leverage an existing high‑speed internet service

We know your background and experience is different and we like that. United Health Group values the skills, experience and dedication that serving in the military demands. In fact, many of the values defined in the service mirror what the United Health Group culture holds true:
Integrity, Compassion, Relationships, Innovation and Performance. Whether you are looking to transition from active duty to a civilian career, or are an experienced veteran or spouse, we want to help guide your career journey. Learn more at (Use the "Apply for this Job" box below).-military

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