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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 DRG Appeals RN utilizes subject matter expertise in DRG auditing to review and provide response to appeals. By partnering with the original auditor, review medical records, and other information to author a rebuttal or agreement with the facility. This person will be instrumental in providing coaching and education to our remote team DRG Validation Specialists utilizing core coding and medical information science.  We are seeking self-motivated, solution oriented and skilled problem solver who provides written documentation in under tight deadlines.  As a DRG Appeals RN, you will derive key insights from the appeals and provide guidance and direction to fellow auditors across our business. 

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 DRG and clinical appeals 
• Respond to Level one, two or higher appeals
• Perform complex conceptual analyses
• Identifies risk factors, comorbidities’, and adverse events, to determine if overpayment 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

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:

• Unrestricted RN (registered nurse) license in your state of residence  
• Inpatient facility DRG experience (coding or auditing)

Preferred Qualifications:

• Existing coding certification, such as RHIT (registered health information technician), RHIA (registered health information administrator), CDIP (certified documentation improvement practitioner), CCS (certified coding specialist), CIC (certified inpatient coder), or CPC (certified professional coder)  
• Experience with ICD10 CM coding and ICD10 PCS coding      
• Managed care experience     
• Healthcare claims experience     
• Investigation and/or auditing experience     
• Proven knowledge of health insurance business, industry terminology, and regulatory guidelines   
• Proficiency with MS Excel, including the ability to create/edit spreadsheets and use sort/filter function

California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $32.60 to $63.99. 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.

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

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.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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