Remote RN: Clinical Claims Audit & Compliance

Registered Nurse; Boston, Northern (MA, KY); Hybrid; USD 83,097,000 - 149,001,000; Full time

Job summary

Optum Insight is seeking a Clinical Claim Review RN in Massachusetts for a full-time, remote role. The RN will perform compliance reviews of medical and administrative documentation to identify fraud, waste, and abuse, using claims data, plan member information, and investigations to document findings.

The position requires 2+ years of health care documentation review, MA RN/LPN license, and ability to travel within Massachusetts up to 25%.

Qualifications

• High School Diploma or equivalent required.
• RN or LPN license active in Massachusetts.
• Minimum 2+ years reviewing healthcare documentation.
• Proficient in MS Office; Excel formulas and data analysis helpful.
• Ability to travel within Massachusetts up to 25%.
• Full-time 40 hours/week, 8 a.m.–5 p.m. with possible overtime.

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

MS Office

Remote work experience

Medical terminology

CPT-4 / HCPCS / ICD-10 familiarity

Claims processing knowledge

Long-term care experience

Travel readiness

Education

High School Diploma/GED or equivalent experience

Nurse licensure (RN or LPN) in Massachusetts

Tools

MS Office Suite

Job description

Optum Insight is seeking a Clinical Claim Review RN in Massachusetts for a full-time, remote role. The RN will perform compliance reviews of medical and administrative documentation to identify fraud, waste, and abuse, using claims data, plan member information, and investigations to document findings.

The position requires 2+ years of health care documentation review, MA RN/LPN license, and ability to travel within Massachusetts up to 25%.