[Hiring] Clinical Claim Review Manager @UnitedHealth Group

Role Description

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.

You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

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 adhere 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.

Qualifications

• A 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.
• Must have a 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).
• Proven self-starter with the ability to handle a fast-paced production environment and multiple review types.

Preferred Qualifications

• Bachelor's Degree.
• Have an RN License in a NLC (Nurse License Compact) state or the ability to apply and meet requirements for one.
• Current knowledge of MCR processes.
• Medicaid or Government Program experience for certain government positions.
• Familiarity with Milliman Care Guidelines or Interqual.
• Proven solid clinical judgement while applying medical necessity based on approved clinical resources and understanding of ICD-10 and CPT/HCPCS codes.
• Proven background involving utilization review for an insurance company, experience in case management, or previous experience with clinical claim review.
• Proven excellent verbal and written communication skills.
• Proven ability to be flexible and willing to adapt to an ever changing environment.

Benefits

• A comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).

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.