Optum
Senior Clinical Appeals RN
Location:
Plymouth, MN
Sign‑on Bonus:
$10,000 for external applicants (not available for current UnitedHealth Group employees).
This role allows telecommuting from any U.S. location within the company’s policy.
Primary 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 understanding and review medical records pertaining to impacted claims
Navigate web‑based portals and independently use online tools and resources including Word, Adobe, and Excel
Serve as a key resource on complex or critical issues and help develop innovative solutions
Define and document/communicate business requirements
Required Qualifications
Associate’s degree (or higher)
Unrestricted RN license in your state of residence
CCS or CIC certification 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 proficiency with ICD‑10‑CM coding including knowledge of principal diagnosis selection, complications and comorbidities (CCs) and major complications and comorbidities (MCCs) and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
Advanced proficiency with ICD‑10‑PCS coding including knowledge of structural components of PCS such as body systems, root operations, body parts, approaches, devices and qualifiers
Preferred Qualifications
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 ability to create/edit spreadsheets and use sort/filter functions
Existing coding certification (e.g., RHIT, RHIA, CDIP, CCS, CIC, CPC)
All telecommuters must adhere to UnitedHealth Group’s Telecommuter Policy
Pay and Benefits Hourly pay ranges from $34.23 to $61.15 based on local labor markets, education, work experience, certifications, and other factors. Benefits include a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution (subject to eligibility requirements). The position complies with applicable minimum wage laws.
Equal Employment Opportunity Statement 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. All positions comply with the San Francisco Fair Chance Ordinance and are subject to a drug‑test requirement before employment. Candidates are required to pass a drug test before beginning employment.
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Plymouth, MN
Sign‑on Bonus:
$10,000 for external applicants (not available for current UnitedHealth Group employees).
This role allows telecommuting from any U.S. location within the company’s policy.
Primary 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 understanding and review medical records pertaining to impacted claims
Navigate web‑based portals and independently use online tools and resources including Word, Adobe, and Excel
Serve as a key resource on complex or critical issues and help develop innovative solutions
Define and document/communicate business requirements
Required Qualifications
Associate’s degree (or higher)
Unrestricted RN license in your state of residence
CCS or CIC certification 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 proficiency with ICD‑10‑CM coding including knowledge of principal diagnosis selection, complications and comorbidities (CCs) and major complications and comorbidities (MCCs) and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
Advanced proficiency with ICD‑10‑PCS coding including knowledge of structural components of PCS such as body systems, root operations, body parts, approaches, devices and qualifiers
Preferred Qualifications
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 ability to create/edit spreadsheets and use sort/filter functions
Existing coding certification (e.g., RHIT, RHIA, CDIP, CCS, CIC, CPC)
All telecommuters must adhere to UnitedHealth Group’s Telecommuter Policy
Pay and Benefits Hourly pay ranges from $34.23 to $61.15 based on local labor markets, education, work experience, certifications, and other factors. Benefits include a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution (subject to eligibility requirements). The position complies with applicable minimum wage laws.
Equal Employment Opportunity Statement 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. All positions comply with the San Francisco Fair Chance Ordinance and are subject to a drug‑test requirement before employment. Candidates are required to pass a drug test before beginning employment.
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