Description

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

This position provides clinical oversight and quality review of 1) Appeal submissions prepared by review partners for escalation to the CMS Independent Review Entity (IRE) on behalf of UHC Payment Integrity, 2) Review partner oversight of Facility DRG audits for coding and clinical accuracy and consistency 3) Review partner oversight of Home Health, Skilled Nursing claims audits, and 4) Oversight of cost outlier audits. The role ensures that clinical arguments are accurate, complete, and defensible, with medical record evidence, coding validation, and policy references clearly articulated and aligned with CMS standards. Responsibilities include reviewing vendor-prepared appeal determinations for clinical validity, clarity, structure, and consistency; identifying gaps or risk areas prior to submission; and collaborating with internal stakeholders to mitigate regulatory and STAR rating risk. The position also supports continuous quality improvement by monitoring IRE outcomes, identifying trends, and driving corrective actions across review partners.

This position reports to the Chief Medical Officer (CMO) for Payment Integrity

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

Primary Responsibilities:

Clinical Responsibilities

• Provide primary clinical and coding quality oversight of review partner appeal submissions prior to escalation to the CMS Independent Review Entity (IRE), ensuring compliance with UHC standards and regulatory timelines
• Review vendor prepared appeals for clinical validity, coding accuracy, clarity, structure, and consistency, confirming that medical record evidence and policy citations fully support the appeal position
• Evaluate appeals against authoritative clinical, coding, and administrative references, including CMS coverage determinations, Clinical Validation Guidelines (CVA), UHC reimbursement policies, and ICD 10 CM/PCS coding standards
• Identify gaps, inconsistencies, or regulatory risk in submissions and direct corrective action, revision, or escalation to ensure defensible IRE submissions
• Triage complex cases requiring CMO involvement and review outcomes of escalated clinical determinations
• Render nurse or analyst level determinations for administrative aspects of appeals based on clinical documentation, policy interpretation, and coding guidance
• Provide clinical and coding oversight of Home Health Prospective Payment System (HH PPS) reviews and cost outlier audit determinations
• Perform second level clinical quality review of cases overturned by the CMS Independent Review Entity (IRE), identifying root causes, documentation deficiencies, and recurring risk patterns
• Monitor IRE outcomes and appeal trends to support continuous clinical quality improvement and reduce repeat deficiencies across review partners
• Collaborate with Payment Integrity, Appeals & Grievances, vendors, and internal stakeholders to mitigate regulatory, compliance, and CMS STAR rating risk related to Non Par appeals
• Demonstrate solid clinical judgment and written communication skills, clearly articulating concise, evidence based clinical and coding rationale in appeal documentation

Administrative Responsibilities

• Coordinate with cross enterprise teams (Optum, vendors, Operations, Network partners, and Payment Integrity leadership) to support priorities impacting submissions
• Summarize and communicate proposed process or technical changes, including documentation of needs, risks, impacts, and expected outcomes, to support stakeholder alignment
• Support planning, execution, and monitoring of process improvement initiatives related to clinical oversight and IRE submission quality
• Identify downstream operational impacts of process changes across Payment Integrity workstreams and recommend adjustments as needed
• Track and communicate changing requirements, priorities, and project status throughout the project lifecycle
• Contribute to the development and maintenance of policies, procedures, training materials, and job aids supporting UCRO and IRE processes
• Foster effective collaboration across matrixed teams by building consensus and supporting resolution of issues
• Apply diplomacy and sound judgment when navigating competing priorities or stakeholder concerns

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 Registered Nurse (RN) license
• Certified Professional Coder (CPC) or equivalent nationally recognized coding certification
• 4+ years of experience performing clinical denial review, appeal preparation, or denial rebuttal writing on behalf of a payer, with demonstrated responsibility for appeal quality and regulatory defensibility
• 1+ years of experience with Inpatient facility DRG coding, auditing, or clinical validation review supporting appeals or payment integrity activities
• Demonstrated expertise applying CMS regulations, coverage determinations, clinical validation principles, and coding standards (ICD 10 CM/PCS, Official Coding Guidelines)
• Advanced proficiency with EMR systems, Microsoft Office tools, (including Word, Excel, Outlook, PowerPoint, CoPilot), and AI/ML to support clinical review, documentation, and reporting

Preferred Qualifications:

• Certification in Clinical Documentation Improvement (CCDS or CDIP)
• Certified Inpatient Coder (CIC) credential
• Experience supporting CMS Independent Review Entity (IRE) submissions, UCRO style vendor oversight, or second level appeal quality review
• Experience with Home Health Prospective Payment System (HH PPS) reviews, including Patient Driven Groupings Model (PDGM) validation
• Experience with Itemized Bill Reviews and Cost Outlier analysis
• Proven involvement in quality improvement, trend analysis, or audit support initiatives related to appeals, clinical validation, or payment integrity

*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 salary for this role will range from $91,700 to $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.