Clinical Claim Review Nurse - National Remote

Lensa; Minneapolis (MN); Remote; Full time

Job summary

A leading company is seeking a Clinical Claim Review Nurse for a national remote position. This role involves conducting forensic reviews, analyzing clinical data, and ensuring compliance with billing guidelines. Ideal candidates will have a strong clinical background, relevant licenses, and excellent communication skills. Join a diverse team dedicated to improving health outcomes and enjoy comprehensive benefits.

Benefits

Comprehensive benefits

Incentives

Stock purchase options

401k contributions

Qualifications

• At least 2 years of clinical experience in an acute care setting.
• Active and unrestricted RN or LPN license.

Responsibilities

• Conduct forensic reviews using clinical knowledge to analyze billed charges.
• Review medical records to evaluate the clinical course of care.
• 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

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

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. Join us to start Caring. Connecting. Growing together.

The Clinical Review Clinician serves as a subject matter expert for itemized bill reviews and hospital facility bill analysis. The clinical reviewer documents, researches, and identifies payment adjustments as part of a team preparing Forensic Reviews for specific clients.

Employees in this role operate with limited supervision within a broad framework of policies and procedures. They possess a comprehensive understanding of the claim review process, including clinical claim review, medical record review, and billing guidelines.

This position offers the flexibility to telecommute* from anywhere within the U.S. to tackle challenging tasks.

Primary Responsibilities

1. Conduct forensic reviews using clinical knowledge to analyze billed charges and determine benefit adjustments.
2. Analyze billing and departmental guidelines.
3. Participate in achieving department goals.
4. Review medical records to evaluate the clinical course of care.
5. Support claims resolution, negotiations, and appeals.
6. Interact with internal partners as needed.
7. Maintain documentation according to departmental standards.
8. Ensure HIPAA confidentiality and privacy standards are upheld.

Research and Special Projects

1. Perform research to support audit adjustments and resolve issues.
2. Research clinical standards and reference materials.
3. Identify new adjustments and business rules.
4. Respond to research inquiries and participate in meetings.

Qualifications

• 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.

Preferred Skills

• Certifications in auditing and coding.
• Experience with medical terminology, coding, billing, and compliance.
• Knowledge of plan benefit language, CMS guidelines, and UB 04 billing.
• Proficiency in Microsoft Excel.
• Strong communication, organizational, and critical thinking skills.
• Adherence to UnitedHealth Group’s Telecommuter Policy.

The salary range is $28.61 to $56.06 per hour, based on full-time employment and various factors. Benefits include comprehensive packages, incentives, stock purchase options, and 401k contributions, subject to eligibility.

We consider qualified applicants with arrest and conviction records, in compliance with the San Francisco Fair Chance Ordinance.

Application deadline details will be posted with the job listing. Our mission is to help people live healthier lives and improve health equity globally. We are committed to diversity, equity, and inclusion, and to mitigating environmental impact. UnitedHealth Group is an Equal Opportunity Employer and a drug-free workplace, requiring a drug test prior to employment.