[Hiring] Clinical Review Nurse @UnitedHealth Group

Role Description

The Clinical Review Clinician serves as a subject matter expert for itemized bill reviews and analyzing hospital facility bills. The clinical reviewer is responsible for documenting, researching and identifying adjustments for payment as part of a team that contributes to the preparation of Forensic Reviews for specific clients.

Employees in this position receive limited supervision within a broad framework of policies and procedures. They possess a comprehensive understanding of the claim review process including clinical claim review, medical record review, and a broad knowledge of applicable processes, procedures and billing guidelines.

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Conduct Forensic Reviews using independent clinical knowledge to compare and analyze charge details of various amounts of total billed charges to determine benefit of full clinical review and estimation of adjustments for the purpose of meeting Optum’s core business operations.
• Complete analysis of billing and departmental guidelines.
• Participate as needed in the achievement and completion of department goals.
• Complete focused review of medical records to evaluate clinical course of care as applicable.
• Assist with resolution of claims as needed to support negotiations and appeals process.
• Interact with internal business partners as requested.
• Maintain appropriate documentation on all claims according to departmental guidelines and procedures.
• Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work.

Other: Research and Special Projects:

• Perform research to support audit adjustments and resolve issues.
• Research reference materials for clinical standards as appropriate.
• Perform research to identify new adjustments and business rules for the goal of meeting core business operations.
• Review and respond to research inquiries from team members and complete special research projects.
• Participate in department and company meetings as requested.

Qualifications

• Associate’s degree (or higher).
• Active and unrestricted RN license OR LPN in the state of residence.
• 2+ years of clinical experience within an acute care setting.
• 1+ years of experience working with bill review.

Requirements

• Auditing and coding certifications.
• Experience working with medical terminology and coding.
• Experience working with billing, charge master and compliance.
• Experience working with plan benefit language, CMS (Medicaid and Medicare) and UB 04 billing guidelines.
• Experience with Microsoft Excel (create, data entry, save).
• Strong written and verbal communication skills.
• Strong organizational and critical thinking skills.

Benefits

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays.
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account.
• Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage.
• 401(k) Savings Plan, Employee Stock Purchase Plan.
• Education Reimbursement.
• Employee Discounts.
• Employee Assistance Program.
• Employee Referral Bonus Program.
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.).