Clinical Claim Review Nurse - National Remote

Lensa; Minneapolis (MN); Remote; USD 100,000 - 125,000; Full time

Job summary

A leading company is seeking a Clinical Claim Review Nurse for a remote position. The role involves forensic reviews of clinical claims and requires a comprehensive understanding of billing guidelines. Ideal candidates will have clinical experience and an active RN or LPN license. The position offers flexibility and a competitive salary range based on experience and certifications.

Benefits

Comprehensive benefits package

Incentive programs

Stock options

401k contributions

Qualifications

• At least 2 years of clinical experience in an acute care setting.
• At least 1 year of experience with bill review processes.

Responsibilities

• Conduct forensic reviews using clinical expertise to analyze billed charges.
• Review medical records to evaluate clinical care pathways.
• Support claims resolution, negotiations, and appeals.

Skills

Communication

Organizational Skills

Critical Thinking

Education

High School Diploma/GED

Tools

Microsoft Excel

Job description

Clinical Claim Review Nurse - National Remote

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Lensa is the leading career site for job seekers at every career stage. Our client, UnitedHealth Group, is seeking professionals. Apply via Lensa today!

Optum, a global organization, delivers technology-enabled care to help millions live healthier lives. Your work will directly improve health outcomes by connecting people with necessary care, pharmacy benefits, data, and resources. We value diversity and inclusion, offer talented peers, comprehensive benefits, and career development opportunities. Join us to make an impact on community health as we advance health equity globally. Together, we are Caring. Connecting. Growing.

The Clinical Review Clinician acts as a subject matter expert in itemized bill reviews and hospital facility bill analysis. Responsibilities include documenting, researching, and identifying payment adjustments as part of a team preparing Forensic Reviews for specific clients.

This role involves limited supervision within broad policies and procedures. Candidates should have a comprehensive understanding of claim review processes, including clinical claim review, medical record review, billing guidelines, and procedures.

You will enjoy the flexibility to telecommute* from anywhere in the U.S. while tackling challenging tasks.

Primary Responsibilities

• Conduct forensic reviews using clinical expertise to analyze billed charges and determine benefit adjustments.
• Analyze billing documents and departmental guidelines.
• Contribute to department goals and objectives.
• Review medical records to evaluate clinical care pathways.
• Support claims resolution, negotiations, and appeals.
• Interact with internal teams as needed.
• Maintain proper documentation per departmental standards.
• Uphold HIPAA confidentiality and privacy standards.

Research and Special Projects

• Perform research to support audit adjustments and resolve issues.
• Review reference materials for clinical standards.
• Identify new adjustments and business rules to meet operational goals.
• Respond to research inquiries and participate in special projects.
• Attend department and company meetings.

Qualifications

Required

• High School Diploma/GED or higher.
• Active and unrestricted RN or LPN license in your state.
• At least 2 years of clinical experience in an acute care setting.
• At least 1 year of experience with bill review processes.

Preferred

• Certifications in auditing and coding.
• Experience with medical terminology, coding, billing, charge master, and compliance.
• Knowledge of plan benefit language, CMS, Medicaid, Medicare, and UB 04 billing guidelines.
• Proficiency in Microsoft Excel.
• Strong communication, organizational, and critical thinking skills.

The hourly salary range is $28.61 to $56.06, based on factors like location, experience, and certifications. UnitedHealth Group offers a comprehensive benefits package, incentive programs, stock options, and 401k contributions. We are committed to diversity, equity, and inclusion, and we consider qualified applicants regardless of background. We are a drug-free workplace requiring pre-employment drug testing.