Clinical Claims Review RN

About the position

At UnitedHealthcare, we are dedicated to simplifying the health care experience and creating healthier communities. As a Clinical Claims Review RN, you will play a crucial role in this mission by conducting retrospective reviews to ensure the appropriateness of various diagnostic procedures, inpatient services, ambulatory care, emergency room visits, and evaluation & management services. Under the direct supervision of the Manager and Supervisors of Clinical Claims Review, you will utilize standardized criteria, protocols, and guidelines to assess claims and ensure compliance with regulatory requirements. This position requires you to reside in Nevada and work in-office, where you will be part of a team that impacts the lives of millions by ensuring quality care and removing barriers to access. In this role, you will provide support across all units within Claims, ensuring that all clinical components meet the standards set by CMS, NCQA, URAC, DOL, DOI, and other state and federal entities. You will identify business priorities and necessary processes to triage and deliver work efficiently. Utilizing appropriate business metrics, you will optimize decisions and clinical outcomes, reviewing assigned claims to evaluate medical necessity and determine the appropriate levels of care and site of service. Your responsibilities will also include maintaining incoming pended claims, electronic inquiries, and medical records work queues, as well as identifying and requesting additional clinical documentation as needed. You will be responsible for making determinations based on relevant protocols, preparing claims for medical director review, interpreting codes, and ensuring coding accuracy. Your role will involve reviewing approved sources of clinical information and participating in various special projects as assigned. Throughout your work, you will be expected to maintain a high degree of discretion and confidentiality in compliance with federal, company, and departmental guidelines. This position offers a rewarding environment where you will be recognized for your performance and provided with opportunities for professional development.

Responsibilities

• Conduct retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services.
• Provide support to all units within Claims to ensure all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities.
• Identify business priorities and necessary processes to triage and deliver work.
• Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes.
• Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service.
• Maintain incoming pended claims, electronic inquiries and medical records work queue.
• Identify information missing from clinical documentation; request additional clinical documentation as appropriate.
• Make determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research).
• Prepare claims for medical director review by completing summary and attaching all pertinent medical information.
• Interpret codes and determine coding accuracy.
• Use available resources to further interpret coding accuracy.
• Identify relevant information needed to make clinical determination.
• Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials).
• Participate in various special projects as assigned.
• Attend assigned meetings relating to clinical reviews and other aspects of job function.
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines.

Requirements

• Registered Nurse with active unrestricted license in the State of Nevada.
• 2+ years of nursing experience in utilization review, case management, clinical claims review, or similar field.
• 1+ years of experience working in a hospital or clinical setting.
• Knowledge of managed care delivery system concepts such as HMO/PPO.
• Ability to learn and differentiate between company products and the benefits.
• Knowledge of evidenced based and standardized criteria such as MCG and InterQual.
• Knowledge of CPT, and ICD-10 coding.
• Broad knowledge of medical conditions, procedures and management.

Nice-to-haves

• Bachelor's degree
• Certified Professional Coder (CPC) certification

Benefits

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