Note: The job is a remote job and is open to candidates in USA. UnitedHealth Group is focused on improving the flow of health data and creating a more connected healthcare system. The IBR Clinical Appeals Analyst role involves performing clinical appeals review, supporting internal quality functions, and participating in training and onboarding activities.
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
Skills
- 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
- 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
Benefits
- A comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution (all benefits are subject to eligibility requirements)
Company Overview