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Clinical Claim Review Nurse – Remote

UnitedHealth Group

This is a Full-time position in Remote- US posted September 14, 2021.

Location: Remote – US

There’s an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn’t for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life’s best work.

The hours for this position are Monday through Friday:

12:00 PM – 9:00 PM CST

Navigate and work within our proprietary electronic medical record system to evaluate and process patient health information to determine outcomes for various types of medical and specialty exams. Conduct a clinical review of a variety of examination documentation, test results, assessments and information to provide a clear, comprehensive and concise final product. Utilize clinical judgement to identify quality assurance issues and make recommendations to reconcile documentation. Collaborate with providers via the nurse call line to ensure examination meets regulatory and contractual requirements for compensation and benefit rating purposes. Possess the ability to shift focus and multitask while maintaining professional demeanor to meet customer and provider needs. Identify emergent behavioral health issues and initiate intervention when necessary.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Mountain or Pacific Time Zones Preferred

Primary Responsibilities:

  • Remain up to date with the contract requirements
  • Use clinical judgement to ensure a clear, comprehensive and concise exam documentation that is reflective of the patient’s service level conditions and in compliance to contract requirements
  • Interpret and document diagnostic test results
  • Educate and support provider with navigating and utilizing medical history information and prior disability claims when completing the appointment paperwork
  • Answer calls that come into the Clinical Operations Review queue in regards to medical or specialty exams and provide exemplary service to providers with appointment questions
  • Identify and evaluate exam documentation that requires immediate follow up for behavioral health issues and initiate the high risk intervention process
  • Complete system generated tasks to process exam documentation
  • Interface via telephone and e-mail with contracted providers in retrieval of required Disability Benefits Questionnaire information and provide education regarding required contractual protocol

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:

  • Accredited Associate’s Degree in Nursing (ADN) OR Bachelor’s Degree in Nursing (BSN)
  • Current RN license in your state of residency
  • 3+ years of experience in a clinical environment as a Registered Nurse
  • Ability to use clinical judgement to interpret test results
  • Understanding of regulatory standards and their application to various examinations and documents
  • Experience working in an Electronic Medical Record system
  • Proficient computer skills including Microsoft Office programs and database experience
  • Excellent verbal and written communication skills
  • Analytical thinking and teamwork skills
  • Ability to perform detailed work with a high degree of accuracy
  • Ability to work 12:00PM – 9:00PM Central Standard Time

Preferred Qualifications:

  • Experience in an Intensive Care Unit or Emergency Room, or Behavioral Health environment
  • Knowledge or experience in regards to: clinical quality assurance; auditing and compliance; education of clinical staff; Clinical Documentation Improvement; clinical experience with Neurological, Cardiovascular or Respiratory units; vision testing, audio testing, reviewing dental images; ISO 9001 standards, and/or other healthcare regulatory and accreditation standards
  • Experience with TBI, PTSD and/or working with Veterans
  • Nurse call line and/or triage line experience
  • Collaborating with providers to ensure quality patient outcomes
  • Knowledge of CPT and ICD9 coding and phlebotomy
  • Military experience

Careers with LHI. Our focus is simple. We’re innovators in cost-effective health care management. And when you join our team, you’ll be a partner in impacting the lives of our customers, and employees. We’ve joined OptumHealth, part of the UnitedHealth Group family of companies, and our mission is to help the health system work better for everyone. We’re located on the banks of the beautiful Mississippi River in La Crosse, Wis., with a satellite office in Chicago and remote employees throughout the United States. We’re supported by a national network of more than 25,000 medical and dental providers. Simply put, together we work toward a healthier tomorrow for everyone. Our team members are selected for their dedication and mission-driven focus. For you, that means one incredible team and a singular opportunity to do your life’s best work.

Colorado Residents Only: The hourly range for Colorado residents is $25.63 to $45.72. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

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

Job Keywords: Quality Assurance, QA, Clinical Review, Electronic Medical Records, RN, Registered Nurse, Telecommute, Work from Home, Salt Lake City, UT, Anchorage, AK, Utah, Alaska