Senior Clinical Appeals SME – Remote

At UnitedHealthcare, 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 Director of Operations, North Carolina Health Plan (UHC Community & State) supports the strategic and day-to-day operational management of the North Carolina Medicaid Health Plan. This role is responsible for ensuring operational excellence across core functions such as claims, call center, enrollment, vendor management, and compliance. The Director will work closely with internal teams and external partners to ensure the health plan meets state requirements, delivers high-quality service, and drives continuous improvement.

 

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

 

Primary Responsibilities: 

• Serve as a subject matter expert (SME) on appeal review processes including prior authorization, claim processing, medical policy interpretation and process application
• Serve as SME for questions from within the team and from partner resources
• Assist UCS Appeals leaders with analyzing the results of the quality audit results and developing action plans for improvement
• Create and present training materials for all business-led training
• Business-led new hire training (after National Training Team is complete)
• Learn new processes, assess impact on team and assist UCS Appeals leaders in developing materials/communicating with the team
• Review and evaluate existing documents for improvement
• Collaborate with other areas to improve processes or address deficiencies
• Provide SME expertise on various projects related to process improvement (e.g., automations, reducing appeals, improving upstream decision-making, system migrations)
• Assist with inventory management responsibilities, as needed, to meet business needs
• Performing individual quality audits (only applies to certain teams)
   

A Day in the Life of Appeals Nurse SME

• Provide accurate and timely responses to general or case specific questions in a clear and concise manner
• Ongoing development and revisions to process-related documents to be utilized by staff for appeal processing
• Lead training sessions (business-led) 
• Participate in project meetings related to process improvements, automations, etc. and follow up on any action items from those meetings
• Provide consultation with project managers to understand appeal process and provide feedback on process implementation
• Assist with case assignments and other inventory management responsibilities to ensure Compliance Due Dates are met
• For certain teams, perform individual quality audits 
  

 

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.

Required Qualifications: 

• RN licensure in state of residence 
• 5+ years of clinical experience as an RN 
• 3+ years of clinical appeals experience 
• Proficiency in MS Office (Word, Excel, PowerPoint, Outlook and OneNote) 
• Proficiency in applicable claim system(s) (if supporting post-service appeals) 
• Proficiency in applicable authorization system (e.g., ICUE/HSR) 
• Proven solid analytical and organizational skills 
• Proven ability to work in a fast-paced environment and manage multiple tasks simultaneously 
• Proven ability to plan, prioritize, organize and complete work to meet established objectives 
• Proven excellent oral, written and interpersonal communication skills 
• Must have a designated quiet workspace in your home (separated from non-workspace areas) and is able to be secured to maintain Protected Health Information (PHI) and/or Protected Information (PI)
• Must have access to install secure high-speed internet (minimum speed 5 download mps and 1 upload mps) via cable/DSL in home (wireless/cell phone provider, satellite, etc. does NOT meet this requirement)
• Ability to work (9 AM – 6 PM Central Time) note: this will be customized based on the specific team needs 
• Currently a member of this M&R Pre-Service Appeals team
   

 

Leadership Priority Skills:

• Delivering excellence and high-quality results
• Life-long learning and seeking stretch opportunities
• Working well with teammates, other teams, managers and customers across department, function and business lines to collaborate

 

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

 

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
 

 

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

 

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.

 

 

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

 

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.