Clinical Claims Review RN

1 month ago

Henderson NV United States UnitedHealth Group Full time
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

Under direct supervision of the Manager and Supervisors, Clinical Claims Review, conducts retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services, coding levels, etc., utilizing standardized criteria, protocols, and guidelines.

This RN will train and provide coverage for the Medical Adjudication and Coding Units in Clinical Claims Review.

Primary Responsibilities:
  • Provide support to all units within Claims to ensure all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities
  • Identify business priorities and necessary processes to triage and deliver work
  • Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes
  • Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service
  • Maintain incoming pended claims, electronic inquiries and medical records work queue
  • Identify information missing from clinical documentation; request additional clinical documentation as appropriate
  • Make determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research)
  • Prepare claims for medical director review by completing summary and attaching all pertinent medical information
  • Interpret codes and determine coding accuracy
  • Use available resources to further interpret coding accuracy
  • Identify relevant information needed to make clinical determination
  • Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials)
  • Participate in various special projects as assigned
  • Attend assigned meetings relating to clinical reviews and other aspects of job function
  • Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines
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 for the state of Nevada
  • 2+ years of nursing experience in utilization review, case management, clinical claims review, or similar field
  • 1+ years of experience working in a hospital or clinical setting.
  • Proficiency with Microsoft Word, Excel and Outlook
Preferred Qualifications:
  • Bachelor's degree
  • CPC certification
  • Knowledge of managed care delivery system concepts such as HMO/PPO
  • Ability to learn and differentiate between company products and the benefits
  • Knowledge of evidenced based and standardized criteria such as MCG
  • Knowledge of CPT, and ICD-10 coding
  • Broad knowledge of medical conditions, procedures and management
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Nevada Residents Only: The salary range for this role is $58,300 to $114,300 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.

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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