Senior Clinical Administrative RN - Remote in Texas

At United Healthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The role focuses on review of member appeals and fair hearing requests - clinical review, chart review, audits, letter review, working with clinical and non‑clinical staff with varied backgrounds to review authorization, UR determinations, in preparation for a Fair Hearing with the State of Texas. The chosen Senior Clinical Administrative RN would be responsible for reviewing appeals and grievances to determine if the appropriate decision was rendered.

In providing consumer‑oriented health benefit plans to millions of people; our goal is to create higher quality care, lower costs, and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.

If you reside within the state of Texas
, you will enjoy the flexibility to work telecommute
* as you take on some tough challenges.

• Works with clinical and non‑clinical staff to review determinations and prepare for Fair Hearings
• Participates in State Fair Hearings
• Coordinates internal reviews on denial letters to determine compliance with contractual and regulatory requirements of the State and Federal programs, while reviewing for efficiencies and effectiveness of procedures
• Reviews electronic Health Records to validate accuracy of decision, recommend revisions, additional documentation, or action to take based on independent review
• Performs internal Quality Control reviews on processes and activities while developing recommendations for improvement
• Serves as a catalyst for implementing an appropriate risk assessment process designed to identify and correct deficiencies
• Assists with the coordination of external audits and reviews conducted by our clients or contracting organizations
• Maintain extensive knowledge of regulatory and applicable accrediting body requirements becoming a Compliance resource for the team
• Proficient in interpreting benefits, contracts, and medical policy
• Review denial notice issued by the National Letter team to ensure accuracy and compliance, as well as providing recommendations for improvement, as needed
• Interact effectively with other departments
• Maintain knowledge of State rules, contracts, and Federal legislation/regulations as well as UHG guidelines
• Establish and maintain good working relationships throughout the company to support goals and objectives
• Demonstrate flexibility, availability, and dependability to conform to position responsibilities
• Ability to work independently or in a team environment
• The applicant should possess a high attention to detail, exceptional documentation abilities, and organizational skills

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

• Active, unrestricted RN license in the state of Texas
• 5+ years of clinical nursing experience, including utilization management, medical necessity review, care management, or a related clinical decision‑making role
• 3+ years of experience with exposure to Appeals, Grievances, or Regulatory processes in a managed care or health plan environment
• 3+ years of experience with knowledge of State and Federal…