Optum · 5 days ago
IBR Clinical Appeals Reviewer - Remote
United States
Full-time
Remote
Entry, Mid Level
$35/hr - $62.50/hr
2+ years expOptum is focused on improving the flow of health data and information to create a more connected system. The IBR Clinical Appeals Reviewer will analyze and respond to client and hospital claim review appeal inquiries, utilizing expertise in auditing to provide clinical reviews with documentation under tight deadlines.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Analyze scope and resolution of IBR Appeals
Respond to Level one, two or higher appeals
Perform complex conceptual analyses
Identifies risk factors, comorbidities', and adverse events, to determine if overpayment or claim adjustment is needed
Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions
Researches and prepares written appeals
Exercises clinical and/or coding judgment and experience
Collaborates with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims
Navigates through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel
Serve as a key resource on complex and / or critical issues and help develop innovative solutions
Define and document / communicate business requirements
Qualification
Required
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
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
Preferred
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
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Benefits
Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
Company
Optum
Optum is a healthcare company that provides pharmacy services, health care operations, and population health management. It is a sub-organization of UnitedHealth Group.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Daniel Castillo
Chief Executive Officer, Optum Care Delivery
J
Jay Green
Chief Financial Officer
Recent News
2025-11-29
2025-11-19
2025-11-07
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