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Clinical Claim Review RN - National Remote ID -10048

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 Claim Review RN will work remotely and independently but also collaborate as part of a specialized team of auditors, office support staff and management. They will be performing quality checks on all completed work for thoroughness and accuracy. The Clinical Claim Review RN will be submitting completed work in a timely manner with attention to client, state, and contractual timeframes. The successful individual will have the ability to adapt to a changing and growing environment.

Schedule: Monday to Friday 8-hour shifts between the hours of 6:30am to 6:30pm within your local time for Eastern Time Zone.

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

Primary Responsibilities

  • Review operative reports, medication administration records, hospital billing and manufacturer invoices to determine if the billing and payment for implants and high-cost drugs are supported by the records, and payment or anticipated payment is accurate according to the contract terms between the payor and the facility
  • Communicate decisions regarding contract and reimbursement determinations
  • Speak with health care facilities to explain audit result and obtain additional clinical information as needed
  • This is high volume, customer service environment. You'll need to be efficient, productive, and thorough dealing with our members over the phone. Strong computer and software navigation skills are critical. You should also be strongly patient-focused and adaptable to changes

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

  • Associate’s Degree (or higher) in Nursing
  • Current and unrestricted Registered Nurse licensure in the state in which you reside
  • 2+ years of clinical documentation review or audit experience, which may include healthcare compliance, post payment audit or clinical documentation improvement
  • Intermediate level of proficiency with MS Word, (create, edit, save documents), Excel and Outlook (email and calendar management) and the ability to navigate on the web through multiple applications

Preferred Qualifications

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 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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