Clinical Claim Review Nurse – National Remote

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Clinical Review Clinician serves as a subject matter expert for itemized bill reviews and analyzing hospital facility bills. The clinical reviewer is responsible for documenting, researching and identifying adjustments for payment as part of a team that contributes to the preparation of Forensic Reviews for specific clients.

Employees in this position receive limited supervision within a broad framework of policies and procedures. Employees in this position possess a comprehensive understanding of the claim review process including clinical claim review, medical record review, and a broad knowledge of applicable processes, procedures and billing guidelines.

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

Claim Review:
• Conduct Forensic Reviews using independent clinical knowledge to compare and analyze charge details of various amounts of total billed charges to determine benefit of full clinical review and estimation of adjustments for the purpose of meeting Optum’s core business operations
• Complete analysis of billing and departmental guidelines
• Participate as needed in the achievement and completion of department goals
• Complete focused review of medical records to evaluate clinical course of care as applicable
• Assists with resolution of claims as needed to support negotiations and appeals process
• Interacts with internal business partners as requested
• Maintains appropriate documentation on all claims according to departmental guidelines and procedures
• Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work

Other: Research and Special Projects:
• Perform research to support audit adjustments and resolve issues
• Research reference materials for clinical standards as appropriate
• Perform research to identify new adjustments and business rules for the goal of meeting core business operations
• Review and respond to research inquiries from team members and complete special research projects
• Participate in department and company meetings as requested

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:
• High School Diploma/GED (or higher)
• Active and unrestricted RN OR LPN in state of residence
• 2 years of clinical experience within an acute care setting
• 1 years of experience working with bill review

Preferred Qualifications:
• Auditing and coding certifications
• Experience working with medical terminology and coding
• Experience working with billing, charge master and compliance
• Experience working with plan benefit language, CMS (Medicaid and Medicare) and UB 04 billing guidelines
• Experience with Microsoft Excel (create, data entry, save)
• Strong written and verbal communication skills
• Strong organizational and critical thinking skills
• All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

The salary range for this role is $28.61 to $56.06 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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 the 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.

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