Clinical Claims Review Manager (RN & CPC Certified)

Optum, a UnitedHealth Group Company; Philippines; On-site; PHP 900,000 - 1,200,000; Full time

Benefits offered by this job

Medical Plan (HMO) from Day 1

Dental, Medical, and Optical Reimburse

Life and Disability Insurance

Paid Time-Off Benefits

Tuition Fee Reimbursement

EAP

Annual Merit Increases

Employee Recognition

Training and Staff Development

Employee Referral Program

All Mandatory Statutory Benefits

Job summary

Optum, a UnitedHealth Group Company, seeks a Clinical Claims Review Manager to lead a team of healthcare professionals in claims review and payment integrity operations.

You will coach staff, manage daily operations, drive performance, and partner with stakeholders to ensure compliant, high-quality service delivery while maintaining industry standards.

Qualifications

• Bachelor's Degree in Nursing (BSN).
• Active nursing background with 2+ years of clinical or bedside experience.
• 3–5 years of leadership experience in a BPO/healthcare operations/shared services.
• CPC certification.
• 1–2 years of medical coding experience.
• Strong understanding of medical records, claims review, reimbursement, and coding guidelines.
• Excellent communication, coaching and stakeholder management skills.

Responsibilities

• Lead and manage daily operations of the Clinical Claim Review team.
• Monitor performance against quality, productivity, adherence, service levels, and turnaround times.
• Provide coaching, mentoring and performance feedback to team members.
• Conduct regular performance reviews and support development plans.
• Collaborate with managers and cross-functional teams to resolve challenges and improve processes.
• Review workflows and identify opportunities for efficiency and continuous improvement.
• Provide SME on clinical documentation, claims review, and coding practices.
• Support compliance initiatives and adherence to policies and healthcare regulations.
• Participate in coding education, calibration meetings and process-improvement activities.
• Handle escalations and support special projects as assigned.

Skills

Leadership

Clinical documentation review

ICD/CPT/HCPCS coding

Analytical skills

Process improvement

Attention to detail

Communication

MS Office

Multitasking

Education

BSN (Bachelor's Degree in Nursing)

Job description

We are looking for an experienced Clinical Claims Review Manager to lead a team of healthcare professionals supporting clinical claims review and payment integrity operations. This role combines clinical expertise, medical coding knowledge, and people leadership to ensure accurate claim review, operational excellence, and high-quality service delivery.

As a people leader, you will oversee daily operations, coach and develop team members, drive performance, and partner with stakeholders to achieve business goals while maintaining compliance with healthcare industry standards.

Key Responsibilities

• Lead and manage the daily operations of the Clinical Claim Review team.

• Monitor team performance against key metrics including quality, productivity, adherence, service levels, and turnaround times.

• Provide coaching, mentoring, and performance feedback to team members.

• Conduct regular performance reviews and support employee development plans.

• Collaborate with managers and cross-functional teams to resolve operational challenges and improve processes.

• Review workflows and identify opportunities for operational efficiency and continuous improvement.

• Provide subject matter expertise on clinical documentation, claims review, and medical coding practices.

• Support compliance initiatives and ensure adherence to company policies and healthcare regulations.

• Participate in coding education sessions, calibration meetings, and ongoing process improvement activities.

• Handle escalations and support special projects and other responsibilities as assigned.

Qualifications

Required

• Bachelor's Degree in Nursing (BSN).

• Active nursing background with at least 2 years of clinical or bedside experience.

• 3 to 5 years of leadership experience in a BPO, healthcare operations, or shared services environment.

• CPC (Certified Professional Coder) certification.

• At least 1 to 2 years of medical coding experience.

• Strong understanding of medical records, claims review, healthcare reimbursement, and coding guidelines.

• Excellent communication, coaching, and stakeholder management skills.

Preferred

• Experience in payment integrity, fraud, waste, abuse, and error (FWAE) programs.

• Claims processing experience within a BPO, healthcare, insurance, or HMO environment.

• AAPC, AHIMA, or equivalent coding certification background.

Skills and Competencies

• Leadership and people management

• Clinical documentation review

• ICD, CPT, and HCPCS coding knowledge

• Analytical and problem-solving skills

• Process improvement and operational excellence

• Strong attention to detail

• Effective communication and stakeholder management

• Microsoft Office proficiency

• Ability to manage multiple priorities in a fast-paced environment

WHAT WE OFFER:

• Market Competitive Pay Levels

• Retirement Plan

• Medical Plan (HMO) from Day 1 of employment

• Dental, Medical, and Optical Reimbursements

• Life and Disability Insurance

• Paid Time-Off Benefits

• Sick Leave Conversion

• Tuition Fee Reimbursement

• Employee Assistance Program (EAP)

• Annual Performance Based Merit Increases

• Employee Recognition

• Training and Staff Development

• Employee Referral Program

• Employee Volunteerism Opportunity

• All Mandatory Statutory Benefits
  

WHO WE ARE:

• Optum is the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare.

• UnitedHealth Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone.

• We're a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center.

• As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world.

• Elevate your career with a leading health care company while improving lives.

Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that's dedicated to Caring. Connecting. Growing together