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RN Clinical Reviewer

1 month ago

PR United States Optum Full time
Job Description

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. 


Positions in this function investigates Optum Waste and Error stopped claims by gathering information, researching state and federal guidelines, and following internal procedure to determine the viability of the claim for further review in a production environment.  


Primary Responsibilities:

  • Clinical Case Reviews -75%

    • 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

    • Provide clear and concise clinical logic to the providers when necessary

    • Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization

    • Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities

    • Investigate and pursue recoveries

    • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance

    • Use pertinent data and facts to identify and solve a range of problems within area of expertise

  • Other internal customer correspondence and team needs - 15%

    • Attend and provide feedback during monthly meetings with assigned internal customer department

    • Provide continuous feedback on how to improve the department relationships with internal team members and departments

  • Continuing education - 10%

    • Keep up required Coding Certificate and/or Nursing Licensure

    • Complete compliance hours as required by the department


*** ENGLISH PROFICIENT ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***


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:

  • Coding Certificate or Nursing Licensure, for example:

    • Puerto Rico Registered Nurse

    • Certified Professional Coder (CPC) + CPC A

    • Certified Inpatient Coder (CIC)

    • Certified Outpatient Auditor (COC)

    • Certified Professional Medical Auditor (CPMA)

    • Certified Coding Specialist (CCS)

  • Proficient with computers, including Microsoft Suite of products

  • Willing or able to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL

  • Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)


Preferred Qualifications:

  • Experience working with medical claims platforms

  • Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting

  • Presentation or policy documentation experience

  • Knowledge of CMS and AMA coding rules specific to CPT, HCPCS

  • Knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations

  • Knowledge of Medicaid/Medicare Reimbursement methodologies

  • Working knowledge of the healthcare insurance/managed care industry

  • Working knowledge of medical terminology and claim coding


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.