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Clinical Appeals Specialist - Remote - 2179712



Owensboro, KY, USA
Posted on Saturday, September 9, 2023

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. 


Opportunities at Owensboro Health, in strategic partnership with Optum. Our team of talented people works to improve the health outcomes of the communities we serve. As an Optum employee, you will provide support to the Owensboro health account. They are a nonprofit system with over 200 providers at more than 20 locations, 3 outpatient facilities, a certified medical fitness facility, a surgical weight loss center and the Mitchell Memorial Cancer Center. We are continually searching for people like you to help us provide the most innovative health care services. Join a team that will make you feel valued and discover the meaning behind.

Clinical Appeals Specialists perform medical necessity reviews for the Clinical Appeals Unit (CAU) This position will work collaboratively with Patient Financial Services (PFS), CDI, and coding staff to coordinate case flow, and to provide guidance regarding denial management. This position will conduct thorough reviews of the medical records and draft appeal letters and discuss cases with client clinical teams. This position will support Optum’s increased focus on streamlining outpatient and inpatient client clinical appeals.  This position will enable CAU to bridge the gaps between CAU, PFS, coding and CDI teams.

Position is telecommuter, with minimal travel requirement. Occasional overnight travel may be required for team building or client engagement but not to exceed 10%.


You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 


Primary Responsibilities: 

  • Triaging denials (Medical necessity vs. Coding vs. Technical) and identifying the root-cause
  • Conducting reviews and responding to insurance denials. Writes concise, factual letters and provides medical record documentation to support appeal. Effectively communicates verbally with external and internal customers to ensure argument for appeal is clearly presented. Responsible for the denials process, including subsequent appeal to health insurance
  • Assures appropriate action is taken within appeal time frames to address denials received by CAU
  • Collaborates with other departments/resources/entities as applicable to ensure the most optimal appeal outcome
  • Utilizes appropriate applications (e.g, Cobius, eCAC/CDI (We currently use Nuance CDE-One and Nuance Clintegrity but ONLY utilize Cobius to track denials) to accurately track clinical denial data; participates in the development and implementation of a system-wide process for appeals
  • Experience in using hospital applications including but not limited to EMR (Epic), Encoders (Nuance Clintegrity360), and CDM tools (Cobius)
  • Has extensive knowledge of applicable Medicare, Medicaid, or Commercial determinations and policies, including Local Coverage Determinations (LCD/LCA), National Coverage Determinations (NCD), Policy Bulletins, etc.
  • Ability to accurately apply utilization review criteria (InterQual) when necessary
  • Assists with continuous quality improvement of the established appeals process
  • Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, discharge disposition, CPT/HCPCS in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance
  • Works in conjunction with multiple units including CDI, coding, legal, Mid/Back rev cycle teams, Providers, payers, and other vendors


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: 

  • Bachelors of Science in Nursing (BSN)
  • Medical school graduate, Physician Assistant, Nurse Practitioner or Registered Nurse (MD, DO, MBBS, PA, NP, or RN). Current, unrestricted RN license for RN applicants
  • 5+ years of acute care nursing experience, preferably in an intensive care unit (ICU)
  • 2+ years of experience writing clinical appeals on behalf of providers
  • Proficient in InterQual acute care guidelines


Preferred Qualifications:          

  • Certification in Clinical Documentation Improvement (CCDS or CDIP)
  • Case Management certification or experience
  • Inpatient or Outpatient Coding certification or experience
  • CDI experience
  • Project management experience
  • Proven solid knowledge of medicine and Pathophysiology with understanding of clinical criteria and treatment of medical diagnoses
  • Proven sound knowledge of principals and basics of charging, medical billing, and reimbursement
  • Proficient in PC use, Microsoft applications (Word, Excel, PowerPoint) and working knowledge of hospital department computer systems
  • Demonstrated clinical discernment/critical thinking skills to identify what defines the patient encounter
  • Proven excellent written communication skills with the ability to clearly articulate ideas and arguments in a letter
  • Proven verbal communication and organization skills
  • Ability to travel on occasion for team building or client engagement but not to exceed 10%


Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges. 


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


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 $67,800 to $133,100. 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.    



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.