Clinical Claim Review Manager

4 weeks ago

Eden Prairie, United States UnitedHealth Group Full time

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

The Clinical Claim Review Manager is responsible for managing a team that is 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 Manager works in a fast paced, ever changing environment with a vigilant focus on improving the member and provider experience.


Schedule: Monday - Friday, business core hours


Primary Responsibilities:

  • Managing a team that is performing clinical claim reviews, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
  • Gathers metric data on staff performance, communicates metric results to direct reports via monthly scorecard and one on one meetings. Follows performance management guidelines
  • Ensures company policies are followed such as but not all inclusive of Attendance, Telecommuting, etc.
  • Communicates process and policy updates to staff timely and clearly
  • Ensures adequate training, precepting and coaching is provided to direct reports as needed
  • Completes all operational reporting and data tracking timely and accurately
  • Ensures work directions and assignments are appropriately communicated and adheres to business metrics
  • Ensures staff development goals are established and supported and align with the MCR One Team growth mindset
  • Participates in pilots, project development, and process changes as requested or when needed
  • Handles manager level issues
  • Actively involved in appropriate management meetings and projects
  • Communicates priorities to the team and embraces a growth mindset
  • Coordinates work activities with other Clinical Claim Review Managers
  • Guides and leads a team to meet individual and team performance metrics
  • Communicates well in writing and verbally
  • Work independently and collaboratively with Medical Directors and non-clinical partners
  • Adapt to a highly changing environment


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 of total RN experience including some clinical experience in an inpatient / acute setting
  • Leadership or supervisory experience
  • Demonstrate a proficiency in computer skills - Windows, Instant Messaging, Microsoft Suite including Word, Excel and Outlook
  • Proven exemplary clinical documentation skills
  • Proven excellent organizational, analytical, and critical thinking skills
  • Proven self-starter with the ability to handle a fast-paced production environment and multiple review types
  • 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 a NLC (Nurse License Compact) state or the ability to apply and meet requirements for one
  • Medicaid or Government Program experience for certain government positions
  • Current knowledge of MCR processes
  • Familiarity with Milliman Care Guidelines or Interqual
  • Background involving utilization review for an insurance company, experience in case management, or experience with clinical claim review
  • Proven solid clinical judgement while applying medical necessity based on approved clinical resources and understanding of ICD-10 and CPT/HCPCS codes
  • Proven excellent verbal and written communication skills
  • Proven ability to be flexible and willing to adapt to an ever changing environment


*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy


California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington or Washington, D.C. Residents Only: The salary range for this role is $88,000 to $173,200 annually. 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.


Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.


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.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.


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

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