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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. The Clinical Claim Review RN is responsible for 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 Nurse works in a fast paced, ever changing environment with a vigilant focus on improving the member and provider experience. This position will work 40 hours per week with extensive training and then a flexible schedule upon completion of training. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Responsibilities
- Perform clinical reviews, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information.
- Function as a member of a self-directed team to meet specific individual and team performance metrics.
- Communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations.
- Work independently and collaboratively with Medical Directors and non-clinical partners.
- Adapt to a highly changing environment and a heavy case load.
Requirements
- A current unrestricted RN license in the state of residency.
- 3+ years total RN experience including clinical experience in an inpatient / acute setting.
- Proficiency in computer skills - Windows, Instant Messaging, Microsoft Suite including Word, Excel and Outlook.
- Proven exemplary clinical documentation skills.
- Proven to be a self-starter with the ability to handle a fast-paced production environment and multiple review types.
- Proven solid written, verbal, analytic, organizational, time management and problem-solving skills.
- 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.
Nice-to-haves
- Bachelor's Degree
- RN License in an NLC (Nurse License Compact) state or the ability to apply and meet requirements for one.
- Professional coding certification and/or core understanding of ICD-10 and CPT/HCPCS codes.
- Medicaid or Government Program experience for certain government positions.
- Background involving utilization review for an insurance company, experience in case management, or previous experience with clinical claim review.
- Familiarity with Milliman Care Guidelines or InterQual.
- Proven solid clinical judgement while applying medical necessity based on approved clinical resources.
- Proven ability to be flexible and willing to adapt to an ever-changing environment.
- Proven excellent time management, organizational and prioritization skills to balance multiple priorities.
Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
