Clinical Claim Review Nurse - National Remote

Lensa; United States; Remote; USD 80,000 - 100,000; Full time

Job summary

A leading company in healthcare is seeking a Clinical Claim Review Nurse to conduct forensic reviews and support claims resolution. This remote role requires clinical expertise and offers a comprehensive benefits package. Join us to make a positive impact on health outcomes.

Benefits

Comprehensive Benefits

Incentives

Stock Purchase

401k

Qualifications

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

Responsibilities

• Conduct forensic reviews using clinical knowledge to analyze billed charges.
• Review medical records to evaluate clinical care.
• Support claims resolution for 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, a global organization delivering care with technology, helps millions live healthier lives. Join us to improve health outcomes by connecting people with care, pharmacy benefits, data, and resources. We value diversity, inclusion, talented peers, comprehensive benefits, and career growth. Make an impact on communities as we advance health equity globally. Join us to start Caring. Connecting. Growing together.

The Clinical Review Clinician is a subject matter expert for 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 the claim review process, including clinical claim review, medical record review, and billing guidelines.

You can telecommute from anywhere within the U.S. while taking on challenging tasks.

Primary Responsibilities

• Conduct forensic reviews using clinical knowledge to analyze billed charges and determine benefit and adjustments.
• Analyze billing and departmental guidelines.
• Participate in achieving department goals.
• Review medical records to evaluate clinical care.
• Support claims resolution for negotiations and appeals.
• Interact with internal partners.
• Document claims according to guidelines.
• Maintain HIPAA confidentiality and privacy standards.

Research and Special Projects

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

We offer a performance-based environment with clear success paths and development opportunities.

Minimum Qualifications

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

Preferred Qualifications

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

The salary range is $28.61 to $56.06 per hour, based on various factors. Benefits include comprehensive packages, incentives, stock purchase, and 401k. We comply with wage laws and are an equal opportunity employer.

We consider qualified applicants with arrest or conviction records per the San Francisco Fair Chance Ordinance. The application deadline is at least 2 business days from posting or until enough candidates are collected.

Our mission is to help people live healthier lives and improve the health system for all, addressing disparities and promoting equity. We are committed to environmental sustainability and equitable care.

UnitedHealth Group is an Equal Employment Opportunity employer and a drug-free workplace requiring a pre-employment drug test.