Clinical Claim Review RN - National Remote ID-13847

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.

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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) and Outlook (email and calendar management), also able to navigate on the web through multiple applications
  • Intermediate level of proficiency with Excel

Preferred Qualifications

  • Operating Room nursing or Infusion experience
  • 2 + years of experience performing audits to verify accurate documentation and reimbursement
  • 1+ years of experience in conflict resolution and ability to identify, define and explain day-to-day problems and solutions
  • 2+ years of Acute care experience
  • Basic knowledge of CPT, ICD10, HCPCS, NUBC or other coding structures
  • Experience calculating drug costs and verifying accurate drug unit billing
  • All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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