Claims Review Manager RN - San Diego, CA

UnitedHealth Group • San Diego, CA

361d • $71,600 - $140,600 • Hybrid

About The Position

Optum CA is seeking a Claims Review Manager RN to join our team in San Diego, CA. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone. At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

Requirements

• High School Diploma / GED
• Must be 18 years of age OR Older
• Prior experience in claims review and/or utilization management in a managed care environment
• Experience with computers and Microsoft Windows environment
• Unrestricted, active California RN License
• Ability to work our normal business hours of 8:00am - 5:00pm, Monday - Friday. It may be necessary, given the business need, to work occasional overtime

Responsibilities

• Review claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group's financial responsibilities, benefit interpretation, and coverage policy.
• Complete claims reviews within established timeframes to maintain compliance with legislative and delegation standards.
• Research genetic testing claims from non-contracted laboratories for coverage appropriateness and make recommendations to the Senior Team for approval or denial.
• Review ad hoc reports related to medical appropriateness, chemotherapy documentation, OB claims, over/under-utilization trends, and other reports as determined by management.
• Make informed decisions on claim appeals, recommending denial or payment, and ensure all claims reviews are processed within established timeframes.
• Supervise employees and interact with all levels of the organization and external contacts.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Industry: Insurance Carriers and Related Activities
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees