Clinical Claim Review RN

Requisition number: 2370152

Job category: Nursing

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.

Primary 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

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.

Required Qualifications:

• 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

Preferred Qualifications:

• A background in utilization review for an insurance company or experience in case management

• Familiarity with Milliman Care Guidelines

Soft Skills :

• Critical thinking skills

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $29.00 to $52.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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