Claims Review Nurse

UnitedHealth Group•San Diego, CA

1d•$29 - $52•Remote

About The Position

The Claims Review Nurse will perform the clinical review of the formal appeal and provider disputes process to ensure the resolution of appeals is consistent with organizational policies and procedures and compliant with state and federal guidelines. Must understand complex medical and regulatory issues for outpatient and inpatient areas to manage the denial through multiple levels of appeal processes involving medical directors at the group and health plan level, as well as representatives from state and federal review regulatory bodies, members, and administrative law judges. Must have a solid command of medicine, medical terminology and comprehensive writing skills in order to document the denial reason at the appropriate literacy. Must be able to do work autonomously. Also, serves as a technical subject matter expert to the team and may be assigned to work on projects that impact departmental workflows. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Graduation from an accredited school of nursing
Active, unrestricted RN Nurse license through the State of California
1+ year of UM/QI in a healthcare setting, or 1+ year experience in an acute care or ambulatory care setting
Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)
Solid knowledge of Microsoft Office
Knowledge of Medicare, DMHC, NCQA, Milliman Care and Health Plan Guidelines

Nice To Haves

Bachelor of Science in Nursing, BSN
2+ or more years of UM/QI and acute care experience in a managed care environment
All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Responsibilities

Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer
Reviews claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group’s financial responsibilities, benefit interpretation, etc.
Reviews contracted Medical Group’s referral requests for medical necessity. Consideration is given to the appropriateness of the setting, place of service, health plan’s benefits and criteria of the requested services and utilizes service matrix for contracted providers. Documents process in authorization system
Ensures the denial reason is documented at an appropriate level of specificity and is easily understandable
Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial
Selects the correct level of hierarchy and applied correctly based on the medical information available
Provides relevant clinical information to the request and the criteria used for decision-making
Ensures the validity of denials of member and provider authorization requests for retrospective services
Maintains required turnaround time (TAT) for processing denials and appeals based on federal and state guidelines
Extrapolates and summarizes medical information and documents findings in relevant tracking system for both denials and appeals. Reviews medical records, notes, and/or detailed billing information as appropriate for appeals responses
Interact with physicians, health plans, physician office staff, and others as needed to complete the denial and appeal processes
Serve as a liaison between internal departments and external providers as required
Functions as the department’s subject matter expert regarding the denial and appeal process
Maintains confidentiality of all patient health information (PHI) in compliance with state and federal law and policy