Sign In
 [New User? Sign Up]
Mobile Version

Clinical Appeals RN - Plano, Texas

UnitedHealth Group

Plano, TX
Job Code:
Apply on the Company Site
  • Save Ad
  • Email Friend
  • Print
  • Research Salary

Job Details

745767 Clinical Appeals RN Plano Texas

Clinical Appeals RN - Plano, Texas (745767)

Position Description

Positions in this function require RN licensure with current unrestricted licensure in applicable state, and may require certification based on role and grade level. Provides clinical support for performing clinical review of appeals, and may also review quality of service issues. Process includes analyzing, reviewing and evaluating appeals in compliance with state and federally mandated turn-around-times and process requirements.

Primary Responsibilities:

  • Educate others regarding guidelines (e.g., Milliman Care Guidelines, CMS), criteria, and procedures (e.g., cases that meet expedited review guidelines, training internal staff)
  • Screen or respond to customer requests (e.g., expedited review, training requests, questions regarding rules/guidelines)
  • Provide feedback/information to internal or external customers (e.g., trends, feedback on prevention of errors, communication of findings)
  • Educates others around new or existing regulatory requirements
  • Find answers to basic questions and determine what other information could provide a more complete understanding of the situation
  • Generally work is self-directed and not prescribed
  • Works with less structured, more complex issues
  • Serves as a resource to others
  • Eventually move into the Supervisor Roll
  • Case Management Review
  • Manage MTAC updates relevant to business that meet expedited review guidelines, training internal staff
  • Review Complex Cases Transgender, BRCA, etc.
  • Manage Quarterly QIMC

This is an office-based position in Plano, Texas. 

Required Qualifications:

  • Must be a licensed RN in the State of Texas
  • 2 years of experience with interpreting plan language / Insurance Benefits
  • Experience in Managing / Supervising a Team of non-clinical analyst
  • Proficient in MS Office

Preferred Qualification:

  • Undergraduate degree or equivalent experience

Careers at UnitedHealthcare Employer & Individual. We all want to make a difference with the work we do. Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine. Here, you get that opportunity every day. As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives. You'll help write the next chapter in the history of health care. And you'll find a wealth of open doors and career paths that will take you as far as you want to go. Go further. This is your life's best work.(sm)



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.



Job Keywords: RN, Clinical Appeals, QIMC, BRCA, Plano, TX, Texas

Job Details

  • Contest Number745767
  • Job TitleClinical Appeals RN - Plano, Texas
  • Job FamilyNursing
  • Business SegmentEmployer and Individual

Job Location Information

  • Plano, TX
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusNon-exempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

Powered ByLogo

Featured Jobs[ View All ]

Featured Employers [ View All ]