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SCA Clinical Claim Review RN
3 months ago
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.
Navigate and work within our proprietary electronic medical record system to evaluate and process patient health information to determine outcomes for various types of medical and specialty exams. Conduct a clinical review of a variety of examination documentation, test results, assessments and information to provide a clear, comprehensive and concise final product. Utilize clinical judgement to identify quality assurance issues and make recommendations to reconcile documentation. Collaborate with providers via the nurse call line to ensure examination meets regulatory and contractual requirements for compensation and benefit rating purposes. Possess the ability to shift focus and multitask while maintaining professional demeanor to meet customer and provider needs. Identify emergent behavioral health issues and initiate intervention when necessary.
You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Mountain or Pacific Time Zones Preferred
Primary Responsibilities:
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Remain up to date with the contract requirements
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Use clinical judgement to ensure a clear, comprehensive and concise exam documentation that is reflective of the patient's service level conditions and in compliance to contract requirements
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Interpret and document diagnostic test results
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Educate and support provider with navigating and utilizing medical history information and prior disability claims when completing the appointment paperwork
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Answer calls that come into the Clinical Operations Review queue in regards to medical or specialty exams and provide exemplary service to providers with appointment questions
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Identify and evaluate exam documentation that requires immediate follow up for behavioral health issues and initiate the high-risk intervention process
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Complete system generated tasks to process exam documentation
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Interface via telephone and e-mail with contracted providers in retrieval of required Disability Benefits Questionnaire information and provide education regarding required contractual protocol
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:
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Accredited Associate's Degree in Nursing (ADN) (or higher)
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Current RN license in your state of residency
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2+ years of experience in a clinical environment as a Registered Nurse
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2+ years of experience working in an Electronic Medical Record system
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Intermediate level of proficiency with the ability to use clinical judgement to interpret test results
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Intermediate level of understanding with regulatory standards and their application to various examinations and documents
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Intermediate level of proficiency with general computer skills including Microsoft Office programs and database experience
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Ability to work 12:00PM - 9:00PM Central Standard Time with the ability to work 1 weekend day in a rotational 8 week schedule
Preferred Qualifications:
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Knowledge or experience in regards to: clinical quality assurance; auditing and compliance; education of clinical staff; Clinical Documentation Improvement; clinical experience with Neurological, Cardiovascular or Respiratory units; vision testing, audio testing, reviewing dental images; ISO 9001 standards, and/or other healthcare regulatory and accreditation standards
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Experience with Behavioral Health, TBI, PTSD and/or working with Veterans
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Nurse call line and/or triage line experience
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Collaborating with providers to ensure quality patient outcomes
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Military experience
Soft Skills:
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Excellent verbal and written communication skills
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Analytical thinking and teamwork skills
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Ability to perform detailed work with a high degree of accuracy
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, Hawaii, Washington, or Washington D.C Residents Only : The hourly range for California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, Hawaii, Washington, or Washington D.C residents is $28.03 to $54.95 per hour. 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.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
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.
