Clinical Grievances RN - Remote in CA

Clinical Grievances Nurse

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

As a Clinical Grievances Nurse, you will be responsible for reviewing incoming retrospective cases to determine if the appropriate care was given along with current cases to ensure the members immediate needs are being addressed. In providing consumer - oriented health benefit plans to millions of people; our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.

If you are able to work PST hours, you will have the flexibility to work remotely* as you take on some tough challenges. The working hours for this role are Monday - Friday, 8 am - 5pm PST.

Primary Responsibilities:

• Perform clinical assessment of healthcare services provided to our members for appropriateness
• Understand relevant state and federal grievance and peer review requirements and accreditation standards applicable for processes supported
• Receives cases from the QIS non- clinical team and reviews them against required clinical information, assessing for appropriateness and consulting with a Medical Director
• Document relevant chronology of case review and provide rationale for severity level, descriptor codes, and any applicable Improvement Action Plan (IAP) implemented
• Facilitate telephonic discussion with health care providers and/or members to obtain additional clinical information
• Provide timely, quality service to members and providers while upholding UnitedHealthcare culture values
• Act as a resource for others with less experience
• Work independently and collaborating with Medical Directors and non-clinical partners
• Function as a member of a self-directed team to meet specific individual and team performance metrics
• Manage and maintain quality and productivity metrics

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:

• Current, unrestricted RN license in the state of residency
• 3+ years of total RN experience including recent clinical experience in an inpatient / acute setting or similar setting
• Demonstrated proficiency in computer skills - Windows, Instant Messaging, Clinical Platforms, Microsoft Suite including Word, Excel, and Outlook
• Demonstrated clinical documentation skills and critical thinking skills
• Designated workspace and access to install secure high speed internet via cable / DSL in home
• Reside in and work 8 am-5 pm Pacific Standard time zone
• Must live in the state of CA

Preferred Qualifications:

• Bachelor's in Nursing or higher
• Experience with Managed Care Clinical Quality Programs
• Case management experience
• Clinical appeals and grievances experience
• Audit / chart review experience
• Experience in a telecommuting role
• Demonstrated ability to effectively utilize UHG applications, including but not limited to authorization applications, auto correspondence, and member & provider demographic systems

*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 $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

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.