Clinical Claim Review Nurse - National Remote

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

Job summary

A leading career site is seeking a Clinical Claim Review Nurse to conduct forensic reviews and billing analysis for a major client. This remote position requires clinical expertise and a commitment to maintaining high standards of confidentiality. Join a team dedicated to improving health outcomes while enjoying comprehensive benefits and career development opportunities.

Benefits

Comprehensive benefits packages

Incentive programs

Stock purchase 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.
• Certifications in auditing and coding preferred.

Responsibilities

• Conduct forensic reviews using clinical knowledge to analyze billed charges.
• Complete billing analysis and review departmental guidelines.
• Support claims resolution, negotiations, and appeals.

Skills

Clinical experience

Communication

Organizational skills

Critical thinking

Education

High School Diploma/GED or higher

Active and unrestricted RN or LPN license

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 is responsible for documenting, researching, and identifying payment adjustments as part of a team that prepares Forensic Reviews for specific clients.

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

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some challenging tasks.

Primary Responsibilities

• Conduct forensic reviews using clinical knowledge to analyze billed charges and determine adjustments.
• Complete billing analysis and review departmental guidelines.
• Participate in achieving department goals.
• Review medical records to evaluate clinical care.
• Support claims resolution, negotiations, and appeals.
• Maintain documentation according to departmental standards.
• Ensure HIPAA confidentiality and privacy standards are upheld.

Research and Special Projects

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

Minimum 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 Qualifications

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

The salary range is $28.61 to $56.06 per hour, based on full-time employment, experience, and other factors. Benefits include comprehensive packages, incentive programs, stock purchase options, and 401k contributions. UnitedHealth Group complies with all applicable wage laws and is an Equal Opportunity Employer.