Note: The job is a remote job and is open to candidates in USA. UnitedHealthcare is simplifying the health care experience and creating healthier communities. The Manager of Clinical Validation provides oversight and quality review for appeal submissions and audits, ensuring compliance with CMS standards and driving continuous quality improvement across review partners.
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
- 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
Skills
- 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
- 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
Benefits
- A comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution (all benefits are subject to eligibility requirements)
Company Overview