Clinical Claim Review RN - Remote

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 Medical 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 Medical Claim Review RN requires the ability to efficiently move between the various review types as required based on business needs of the department. Strong 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.

Hours are Monday through Friday from 8AM to 5PM within your local time zone.

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 state of residence
• 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

Preferred Qualifications:

• Utilization Management experience
• Prior authorization experience
• Medical claims review or claims processing experience
• CMS, MCG and/or InterQual criteria experience

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

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.


Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.