Requisition Number: 2236783
Job Category: Nursing
Primary Location: Eden Prairie, MN
(Remote considered)
For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.
The Optum Care Clinical Claim Review team conducts retrospective, post-service clinical reviews to determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. This role requires the application of critical thinking skills, along with medical and reimbursement policies. Review types include outpatient professional claims, DRG readmission and retro, first and second level reconsideration reviews for the medical necessity of inpatient level of care. The Clinical Claim Review RN requires the ability to efficiently move between the various review types as required based on business needs of the department. Solid knowledge of claims processing and utilization management is preferred.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Review and interpret clinical documentation (e.g., anesthesia records, operative reports, progress notes, therapy notes, discharge plans)
- Make determinations per relevant protocols and clinical judgement
- Use available resources to interpret coding accuracy
- Apply clinical and departmental guidelines (e.g., CMS, MCG, medical and reimbursement policies)
- Interpret and apply applicable Federal and State mandates
- Summarize clinical information and provide medical recommendations to medical directors
- Adhere to relevant quality audit standards in performing reviews, making determinations and documentation
- Apply critical thinking skills and professional nurse judgement to solve moderately complex problems
- Works with minimal guidance; seeks guidance on only the most complex tasks
- Acts as a resource for others with less experience
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 RN licensure in applicable state
- MCG certification, or willing to obtain within 2 years of hire
- 5+ years of RN experience
- 2+ years of RN experience in an acute care facility
- Solid computer literacy, Microsoft Office Suite
- Proven ability to type 45 Words Per Minute
- Location/workspace in the home separate from non-workspace areas that can be secured
- Live in a location that can receive high speed internet connection
Preferred Qualifications:
- Certified Professional Coder (CPC)
- Current unrestricted RN licensure in Nevada
- Utilization Management experience
- Medical claims review or claims processing experience or prior authorization experience
- CMS, MCG and/or InterQual criteria experience
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. 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.
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.