Clinical Claim Review RN

University of Minnesota School of Nursing; Boston, Northern (MA, KY); Hybrid; USD 40,000 - 72,000; Full time

Job summary

UnitedHealth Group in Massachusetts is seeking a Clinical Claim Review RN to perform compliance reviews of medical and administrative documentation, identifying fraud, waste, and abuse. The role involves site visits, data analysis, and presenting audit findings to clients using our auditing tools.

The position is full-time, remote within Massachusetts, with standard 8-hour shifts and occasional overtime. The ideal candidate will have an active nursing license (RN/LPN), 2+ years of review

Qualifications

• High School Diploma/GED OR equivalent work experience
• Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts
• 2+ years of experience reviewing health care documentation in a clinical or administrative role
• Experience with MS Office Suite, specifically Word, PowerPoint, and Excel (including familiarity with basic formulas and data analysis)
• Ability to travel up to 25% of the time within the state of Massachusetts as business needs dictate
• Ability to work full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime
• Must have a valid driver's license
• Must be 18 years of age OR older

Responsibilities

• Review medical and administrative records for audit/compliance review
• Travel to provider sites up to 25%/month to collect records and engage with providers
• Present and participate in discussions with the client regarding audit observations and findings
• Collaborate with a team of 2-5 auditors to complete reviews
• Enter audit findings data and notes in online/electronic platform using Excel-based templates
• Attend and participate in dispute reviews and administrative hearings
• Demonstrated written and verbal communications skills
• Demonstrated customer service skills

Skills

RN licensure

MS Office Suite

Travel 25% within MA

Full-time availability

Valid driver's license

18+ years old

Education

High School Diploma or GED

RN or LPN licensure (MA)

Job description

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.

The Clinical Claim Review RN will be responsible for performing compliance reviews of medical and administrative documentation to identify instances of healthcare fraud and/or wasteful and abusive conduct by health care providers who submit claims for payment. This position will utilize information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations in order to document relevant findings. The Clinical Claim Review RN will conduct site visits and desk audits of provider claims, and medical and administrative records, to gather and analyze all necessary information to determine whether subject adhered to state and federal compliance policies, reimbursement policies, and contract compliance. The Sr. Recovery Resolution Analyst will present and discuss audit findings with clients and input information into Optum audit workflow tools and the client's case tracking system. Where applicable, the Auditor will support appeal and fraud investigation activities.

This position is full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime.

We offer weeks of on-the-job training. The hours of the training will be aligned with your schedule.

This position is Remote in Massachusetts. You will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Review medical and administrative records for audit/compliance review
• Travel to provider sites up to 25%/month to collect records and engage with providers
• Present and participate in discussions with the client regarding audit observations and findings
• Collaborate with a team of 2-5 auditors to complete reviews
• Enter audit findings data and notes in online/electronic platform using Excel-based templates
• Attend and participate in dispute reviews and administrative hearings
• Demonstrated written and verbal communications skills
• Demonstrated customer service skills

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School Diploma/GED OR equivalent work experience
• Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts
• 2+ years of experience reviewing health care documentation in a clinical or administrative role
• Experience with MS Office Suite, specifically Word, PowerPoint, and Excel (including familiarity with basic formulas and data analysis)
• Ability to travel up to 25% of the time within the state of Massachusetts as business needs dictate
• Ability to work full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime
• Must have a valid driver's license
• Must be 18 years of age OR older

Preferred Qualifications:

• Clinical or administrative experience in long term care, for example, nursing facility care delivery/administration and/or community-based LTC service programs like Home Health
• Experience in claim processing, healthcare provider information, and healthcare billing practices
• Experience working in a remote/telecommute workspace
• Working knowledge of medical terminology and claim coding with familiarity of CPT-4, HCPCs and ICD-10 code terminology
• Familiarity with Medicaid program and/or billing requirements

Telecommuting Requirements:

• Reside within Massachusetts
• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service Join a team that's committed to shaping the future of health care. Help improve life for millions as you do your life's best work

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone—of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug‑free workplace. Candidates are required to pass a drug test before beginning employment.

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