IRR Clinical Claim Review RN

UnitedHealth Group; Massachusetts; On-site; USD 40,000 - 72,000; Full time

Benefits offered by this job

Paid time off + holidays

Medical/Dental/Vision insurance

401(k) Savings Plan

Job summary

The IRR Clinical Claim Review Nurse at UnitedHealth Group performs claim reviews to verify coding and charges, researching guidelines to determine claim viability. This role suits professionals with clinical experience and a solid understanding of the claim review process.

Based in Plymouth, MA with a full-time day shift, the position supports remote work anywhere in the U.S. while complying with HIPAA, state and federal regulations.

Qualifications

• Associate's degree required.
• 2+ years of clinical experience within an acute care setting.
• 1+ years of experience in Utilization Management, pre-authorization, claim review, appeals review, or medical record review.
• Active and unrestricted RN license in the state of residence required.
• Auditing and coding certifications preferred or ability to obtain within 1 year of employment.

Responsibilities

• Perform clinical review of professional or facility claims vs. medical records.
• Maintain standards for productivity and accuracy defined by the department.
• Complete analysis of billing and departmental guidelines.
• Provide clear and concise clinical logic to clients and providers.
• Participate in the achievement and completion of department goals.
• Complete focused review of medical records to evaluate clinical course of care.
• Assist with resolution of claims to support negotiations and appeals process.
• Ensure adherence to state and federal compliance policies.
• Maintain appropriate documentation on all claims according to departmental guidelines.
• Understand and maintain HIPAA confidentiality and privacy standards.

Skills

Clinical review

Documentation accuracy

HIPAA compliance

Education

Associate's degree

RN license in state of residence

Auditing and coding certifications (CPC, CIC, CIC, CPB, CPMA)

Job description

About This Role

The IRR Clinical Claim Review Nurse performs claim reviews to verify correct coding and charges, documenting and researching state and federal guidelines to determine claim viability. This role is ideal for those with a comprehensive understanding of the claim review process and a background in clinical settings.

Highlights

• Location: Plymouth, MA
• Schedule: Full Time, Day shift
• Pay: $29 - $52 per hour
• Residency: Must reside in the U.S.
• Work Style: Telecommute from anywhere within the U.S.

What You’ll Do

• Perform clinical review of professional or facility claims vs. medical records.
• Maintain standards for productivity and accuracy defined by the department.
• Complete analysis of billing and departmental guidelines.
• Provide clear and concise clinical logic to clients and providers.
• Participate in the achievement and completion of department goals.
• Complete focused review of medical records to evaluate clinical course of care.
• Assist with resolution of claims to support negotiations and appeals process.
• Ensure adherence to state and federal compliance policies.
• Maintain appropriate documentation on all claims according to departmental guidelines.
• Understand and maintain HIPAA confidentiality and privacy standards.

Requirements

Education:

• Associate's degree required

Experience:

• 2+ years of clinical experience within an acute care setting
• 1+ years of experience in Utilization Management, pre-authorization, claim review, appeals review, or medical record review

Licenses & Certifications:

• Active and unrestricted RN license in the state of residence required
• Auditing and coding certifications preferred (CPC, COC, CIC, CPB, CPMA) or ability to obtain within 1 year of employment

Benefits

• Paid Time Off which accrues with the first pay period plus 8 Paid Holidays
• Medical Plan options with Health Spending Account or Health Saving Account
• Dental, Vision, Life & AD&D Insurance, Short-term and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

About UnitedHealth Group

UnitedHealth Group is a leading healthcare provider committed to delivering exceptional patient care. They focus on helping people live healthier lives and improving the health system for everyone. Their culture emphasizes inclusion, career development, and comprehensive benefits.