IRR Clinical Claim Review RN

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 IRR Clinical Claim Review Nurse performs claim reviews to verify correct coding and correct charges. The clinical reviewer is responsible for documenting, researching state and federal guidelines and following internal procedures to determine the viability of the claim for further review in a production environment.  Employees in this position receive limited supervision within a broad framework of policies and procedures and possess a comprehensive understanding of the claim review process including clinical claim review, medical record review, and a broad knowledge of applicable processes, procedures and billing guidelines.

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

Clinical Claim Reviews:

• Perform clinical review of professional or facility claims vs. medical records to determine if the claim is supported or unsupported
• Maintain standards for productivity and accuracy.  Standards are defined by the department
• Complete analysis of billing and departmental guidelines
• Provide clear and concise clinical logic to the clients and providers when necessary
• Participation as needed in the achievement and completion of department goals
• Complete focused review of medical records to evaluate clinical course of care as applicable
• Assists with resolution of claims as needed to support negotiations and appeals process
• Ensue adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Maintains appropriate documentation on all claims according to departmental guidelines and procedures
• Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work 

What are the reasons to consider working for UnitedHealth Group?   Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability 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.)

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:

• Associate's degree
• Active and unrestricted RN license in the state of residence
• 2+ years of clinical experience within an acute care setting
• 1+ years of experience in one of the following areas Utilization Management, pre-authorization, claim review, appeals review, or medical record review
• Intermediate level of computer skills including proficiency in Microsoft Office, Word, Excel, Outlook, and SharePoint

Preferred Qualifications:

• Auditing and coding certifications (CPC, COC, CIC, CPB, CPMA) or ability to obtain within 1 year of employment
• CP