IBR Clinical Appeals Analyst - 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.

The Internal Quality Analyst for Itemized Bill Review (IBR) Clinical Appeals is an experienced RN who performs clinical appeals review responsibilities while also supporting internal quality, process documentation, training, onboarding, and implementation activities. This role analyzes and responds to client and/or hospital claim review appeal inquiries, completes medical record review, evaluates data, and prepares written response resolutions for clients and the business unit. In addition, this role serves as a team resource for focused audits, second-set-of-eyes reviews, process updates, new client implementations, and process improvement opportunities that support metric performance, SLA maintenance, and overall quality improvement.

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.

Primary Responsibilities:

• Analyze scope and resolution of IBR Clinical Appeals, including medical record review, claim review data analysis, and preparation of written appeal responses
• Respond to level one, level two, or higher-level appeals using clinical judgment, coding knowledge, regulatory guidance, payer protocols, and medical policy
• Perform complex conceptual analyses to identify risk factors, comorbidities, adverse events, overpayment opportunities, and claim adjustment needs
• Complete internal quality functions, including second-set-of-eyes reviews, focused audits, targeted quality checks, and feedback support to promote accuracy and consistency
• Support training and onboarding of new hires through job aids, process demonstrations, case review support, and ongoing knowledge reinforcement
• Maintain, update, and communicate process documentation, standard work, workflows, and team resources to support operational alignment
• Participate in new client implementations by supporting process readiness, training needs, documentation updates, workflow validation, and post-implementation quality monitoring
• Partner with auditors, quality, operations, and leadership teams to review impacted claims, identify trends, resolve issues, and recommend process improvements
• Serve as a key team resource on complex and/or critical issues, team initiatives, projects, and process improvement opportunities
• Define, document, and communicate business requirements, process changes, quality expectations, and implementation-related updates
• Navigate web-based portals and independently use online tools and resources, including Microsoft Word, Adobe, Excel, and other business systems, to complete appeals, quality, training, and documentation activities

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:

• 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  
• Experience supporting internal quality functions, including focused audits, second-set-of-eyes reviews, quality monitoring, and/or feedback support
• Experience supporting process documentation, workflow updates, standard work, job aids, training materials, or implementation-related resources
• Experience training, onboarding, mentoring, or serving as a team resource for new hires, peers, or business partners
• Experience participating in process improvement activities, team initiatives, client implementations, or projects supporting SLA, quality, and metric performance
• Advanced experience with regulations, compliance and composing professional appeal responses
• Advanced experience with ICD10 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 UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

Preferred Qualifications:

• Experience as a Team Lead or Subject Matter Expert (SME)
• 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 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 $35 - $63 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.