IBR Clinical Appeals Reviewer - Remote

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives?

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 8:00am ‑ 5:00pm. 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
• Identifies risk factors, comorbidities', and adverse events, to determine if over payment or claim adjustment is needed
• Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions
• Researches and prepares written appeals
• Exercises clinical and/or coding judgment and experience
• Collaborates with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims
• Navigates through web‑based portals and independently utilizes 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
• 2+ years of 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 8:00am ‑ 5:00pm
• Proven ability to keep all company sensitive documents secure (if applicable)
• Have a dedicated work area established that is separated from other living areas and provides information privacy
• Live in a location that can receive a United Health Group approved high‑speed internet connection or leverage an existing high‑speed internet service

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

* All employees working remotely will be required to adhere to United Health 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 $35.00 to $62.50 per hour based on full‑time employment. We comply with all minimum wage laws as applicable.

This will be posted for a minimum of 2 business days or until a sufficient…