Clinical Claim Review RN - Remote

Optum; Eden Prairie (MN); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Claim Review RN to perform clinical reviews and enhance health outcomes by working with state and federal guidelines. This position offers flexible remote work across the U.S. and requires a current RN license along with significant experience in an acute setting. You will be part of a self-directed team striving for excellence in member and provider outcomes, rewarded for your performance in a supportive environment.

Benefits

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Qualifications

• 3+ years of RN experience in an inpatient/acute setting.
• Must have proficiency in computer skills – Windows, Microsoft Suite (Word, Excel, Outlook).
• Ability to work in a fast-paced, changing environment with multiple reviews.

Responsibilities

• Perform clinical reviews and interpret mandates and benefit language.
• Communicate coverage guidelines and reimbursement determinations.
• Work collaboratively with Medical Directors and adapt to a heavy case load.

Skills

Clinical documentation

Analytic skills

Organization skills

Problem-solving skills

Education

Bachelor's Degree

Current unrestricted RN license

Tools

Microsoft Suite

Job description

21 hours ago Be among the first 25 applicants

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Clinical Claim Review RN is responsible for performing clinical reviews post service utilizing established guidelines and clinical criteria along with state and federal mandates and applicable benefit language to make determinations that drive better provider and member outcomes and lower the cost of care. The Clinical Claim Review Nurse works in a fast paced, ever changing environment with a vigilant focus on improving the member and provider experience.

Schedule: This position will work 40 hours per week with a flexible schedule

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

• Perform clinical reviews, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
• Function as a member of a self-directed team to meet specific individual and team performance metrics
• Communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations
• Work independently and collaboratively with Medical Directors and non-clinical partners
• Adapt to a highly changing environment and a heavy case load
  
  

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

Required Qualifications

• Current unrestricted RN license in the state of residency
• 3+ years total RN experience including clinical experience in an inpatient / acute setting
• Proficiency in computer skills - Windows, Instant Messaging, Microsoft Suite including Word, Excel and Outlook
• Proven exemplary clinical documentation skills
• Proven to be a self-starter with the ability to handle a fast-paced production environment and multiple review types
• Proven solid written, verbal, analytic, organizational, time management and problem-solving skills
• Quiet secure designated work space and access to install secure high speed internet (minimum speed 1.5 download mps & 1 upload mps) via cable / DSL in home (wireless / cell phone provider, satellite, microwave, etc does not meet this requirement)
  
  

Preferred Qualifications

• Bachelor's Degree
• RN License in an NLC (Nurse License Compact) state or the ability to apply and meet requirements for one
• Professional coding certification and/or core understanding of ICD-10 and CPT/HCPCS codes
• Medicaid or Government Program experience for certain government positions
• Background involving utilization review for an insurance company, experience in case management, or experience with clinical claim review
• Familiarity with InterQual
• Proven solid clinical judgement while applying medical necessity based on approved clinical resources
• Proven ability to be flexible and willing to adapt to an ever-changing environment
• Proven excellent time management, organizational and prioritization skills to balance multiple priorities
• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
  
  

The hourly range for this role is $28.61 to $56.06 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

Referrals increase your chances of interviewing at Optum by 2x

Sign in to set job alerts for “Registered Nurse” roles.

Greater Minneapolis-St. Paul Area $40.48-$67.00 1 day ago

Registered Nurse - Medical/Surgical - RN

Home Health Registered Nurse - Sign On Bonus - Flex Schedule - Day Shifts

Minneapolis, MN $77,000.00-$93,600.00 11 hours ago

RN Staff Development Coordinator 7500 Bonus

Day Nurse RN/LPN for Toddler in Richfield, MN

Greater Minneapolis-St. Paul Area $40.48-$67.00 2 weeks ago

Inpatient Care Management Nurse RN - Remote

Day Nurse RN/LPN for Toddler in Richfield, MN

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.