Clinical Claim Review Nurse at UnitedHealth Group

Remote
UnitedHealth Group

Title: Clinical Claim Review Nurse

  • Location: United States

Compassion. It’s the starting point for health care providers like you and it’s what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you’re also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life’s best work,

At Optum, the mission is clear: Help people live heathier lives and help make the health system work better for everyone.

LHI is one of 4 businesses under OptumServe. OptumServe provides health care services and proven expertise to help federal government agencies modernize the U.S. health system and improve the health and well being of Americans. By joining OptumServe you are part of the family of companies that make UnitedHealth Group a leader across most major segments in the U.S. health care system.

LHI was founded in 1999 and acquired by Optum in 2011, LHI specializes in creating and managing health care programs through on location services, patient specific in clinic appointments, telehealth assessments, or any combination based on customer need.

LHI’s customizable solutions serve the diverse needs of commercial customers, as well as federal and state agencies, including the U.S. Departments of Defense, Veterans Affairs, and Health and Human Services.

There’s an energy and excitement here, a shared mission to improve the lives of others as well as our own. Ready for a new path? Start doing your life’s best work.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

The hours for this position are Monday through Friday:

  • 10:00 AM 7:00 PM CST
  • 12:00 PM 9:00 PM CST

Navigate and work within our proprietary electronic medical record system to evaluate and process patient health information to determine outcomes for various types of medical and specialty exams. Conduct a clinical review of a variety of examination documentation, test results, assessments and information to provide a clear, comprehensive and concise final product. Utilize clinical judgement to identify quality assurance issues and make recommendations to reconcile documentation. Collaborate with providers via the nurse call line to ensure examination meets regulatory and contractual requirements for compensation and benefit rating purposes. Possess the ability to shift focus and multitask while maintaining professional demeanor to meet customer and provider needs. Identify emergent behavioral health issues and initiate intervention when necessary.

Primary Responsibilities:

  • Remain up to date with the contract requirements
  • Use clinical judgement to ensure a clear, comprehensive and concise exam documentation that is reflective of the patient’s service level conditions and in compliance to contract requirements
  • Interpret and document diagnostic test results
  • Educate and support provider with navigating and utilizing medical history information and prior disability claims when completing the appointment paperwork
  • Answer calls that come into the Clinical Operations Review queue in regards to medical or specialty exams and provide exemplary service to providers with appointment questions
  • Identify and evaluate exam documentation that requires immediate follow up for behavioral health issues and initiate the high risk intervention process
  • Complete system generated tasks to process exam documentation
  • Interface via telephone and e-mail with contracted providers in retrieval of required Disability Benefits Questionnaire information and provide education regarding required contractual protocol

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:

  • Accredited Associate’s Degree in Nursing (ADN) OR Bachelor’s Degree in Nursing (BSN)
  • Current RN license in your state of residency
  • 3+ years of experience in a clinical environment as a Registered Nurse
  • Ability to use clinical judgement to interpret test results
  • Understanding of regulatory standards and their application to various examinations and documents
  • Experience working in an Electronic Medical Record system
  • Proficient computer skills including Microsoft Office programs and database experience
  • Excellent verbal and written communication skills
  • Analytical thinking and teamwork skills
  • Ability to perform detailed work with a high degree of accuracy
  • If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders

Preferred Qualifications:

  • Experience in an Intensive Care Unit or Emergency Room, or Behavioral Health environment
  • Knowledge or experience in regards to: clinical quality assurance; auditing and compliance; education of clinical staff; Clinical Documentation Improvement; clinical experience with Neurological, Cardiovascular or Respiratory units; vision testing, audio testing, reviewing dental images; ISO 9001 standards, and/or other healthcare regulatory and accreditation standards
  • Experience with TBI, PTSD and/or working with Veterans
  • Nurse call line and/or triage line experience
  • Collaborating with providers to ensure quality patient outcomes
  • Knowledge of CPT and ICD9 coding and phlebotomy
  • Military experience

Careers with LHI. Our focus is simple. We’re innovators in cost-effective health care management. And when you join our team, you’ll be a partner in impacting the lives of our customers, and employees. We’ve joined OptumHealth, part of the UnitedHealth Group family of companies, and our mission is to help the health system work better for everyone. We’re located on the banks of the beautiful Mississippi River in La Crosse, Wis., with a satellite office in Chicago and remote employees throughout the United States. We’re supported by a national network of more than 25,000 medical and dental providers. Simply put, together we work toward a healthier tomorrow for everyone. Our team members are selected for their dedication and mission-driven focus. For you, that means one incredible team and a singular opportunity to do your life’s best work.(sm)

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