Clinical Claim Review RN
About The Position
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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. It feels great to have autonomy, though there's also a lot of responsibility that comes with it. In this role, you'll be accountable for making decisions that directly impact our members. And at the same time, you'll be challenged by a demanding case load in a rapidly-changing, production-driven environment. If you are located in the state of Massachusetts, you will enjoy the flexibility to telecommute as you take on some tough challenges.
Requirements
- Associate's degree
- Current unrestricted RN license in the state of Massachusetts
- 3+ years of experience as a RN, including experience in an inpatient/acute setting
- 1+ years of clinical documentation experience
- A designated homework space with access to install secure high-speed internet via cable/DSL
Nice To Haves
- A background in utilization review for an insurance company or experience in case management
- Familiarity with Milliman Care Guidelines
- Critical thinking skills
Responsibilities
- Perform clinical coverage review services, which require interpretation of state and federal mandates, applicable benefit language and consideration of relevant clinical information
- Communicate all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations
- Speak with health care providers and/or members to explain benefit coverage determinations and obtain additional clinical information
Benefits
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
