Requisition Number: 2207744
Job Category: Medical & Clinical Operations
Primary Location: Phoenix, AZ
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The Manager of Clinical Appeals will have regional accountability for oversight and performance of Clinical Appeals Unit (CAU) for OptumInsight clients. The Manager will provide strong leadership in operations driving performance, managing change, building teams, and positively influencing in a highly matrixed organization. The individual will drive continual improvement in operational performance, appeal outcome and client satisfaction. This position will lead an interdisciplinary team and drive employee engagement and collaborate with other functional leaders to evolve program design and delivery. This position is remote occasional travel for in-person meetings.
If you are located in PST or MST time zones, you will have the flexibility to work remotely* as you take on some tough challenges.
- Manage Clinical Appeals Unit staff and daily workflow for the production of written clinical appeals
- Develop and execute appeals management strategies for all areas of hospital denials (inpatient, outpatient, observation, medical necessity, level of care, etc.). Assure appropriate action is taken within appeal time frames to address clinical denial
- SME on denial rationales and identifies primary denial issue
- Provide feedback and coach staff on well written appeal arguments based on clinical evidence within the medical record and evidence-based literature
- Ensure CAU appeals follow current industry clinical guidelines, evidence based medical, community and national medical management standards and protocols
- Provide clinical support for producing high quality, timely, and effectively written clinical appeals
- Evaluate performance and holds the team accountable
- Inspires high performance and production
- Communicate identified denial trends and root cause analysis to internal and client leadership
- Utilize appropriate applications (MIDAS+, Veracity, Artiva, eFR) to accurately track clinical denial data; participates in the development and implementation of a system-wide process for appeals
- Assist with continuous quality improvement of the established appeals process
- Direct others to resolve business problems that affect multiple functions or disciplines
- Identify operational efficiencies to enhance operations, reduce operating costs, and standardize best practices across the organization
- Create/update of denial templates for appeals staff
- Ensure consistent service levels are maintained through managing staffing levels, monitoring metrics, process improvement, and human resource management
- Systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
- Identify and resolve technical, operational, and organizational problems outside own team
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.
- Medical school graduate, physician assistant, nurse practitioner or registered nurse (MD, DO, MBBS, PA, NP, or RN). Current, unrestricted RN license for RN applicants
- 3+ years of work directly related to clinical appeals in an acute hospital setting
- Expertise with the use of evidence based inpatient guidelines and criteria
- Knowledge of third-party payer requirements for reimbursable care
- Knowledge of basic CMS rules and regulations pertaining to reimbursable care
- Solid operations experience
- Proven record in driving substantial quantifiable operational improvements
- Proficient in Microsoft Word, Excel, Power Point, Outlook and PowerBI
- Ability to interpret and perform complex data analyses using Excel and PowerBI
- Ability to influence and negotiate
- Leadership in environment of rapid change
- Ability to work in highly matrixed environment
- Ability to establish trust and credibility at all levels of the organization
- Demonstrated problem-solver; resourceful
- InterQual and/or MCG certification
- CPC, CCS or equivalent Coding Certification
- Certification in Clinical Documentation Improvement
- Previous management experience in clinical appeals
- Training in data analytics
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
California, Colorado, Nevada or Washington Residents Only: The salary range for California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington residents is $88,000 to $173,200 annually. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
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.
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