Claims Review Nurse

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California, to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions. 

The Claims Review Nurse will perform the clinical review of the formal appeal and provider disputes process to ensure the resolution of appeals is consistent with organizational policies and procedures and compliant with state and federal guidelines. Must understand complex medical and regulatory issues for outpatient and inpatient areas to manage the denial through multiple levels of appeal processes involving medical directors at the group and health plan level, as well as representatives from state and federal review regulatory bodies, members, and administrative law judges. Must have a solid command of medicine, medical terminology and comprehensive writing skills in order to document the denial reason at the appropriate literacy. Must be able to do work autonomously. Also, serves as a technical subject matter expert to the team and may be assigned to work on projects that impact departmental workflows.

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

Primary Responsibilities:

• Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer
• Reviews claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group’s financial responsibilities, benefit interpretation, etc.
• Reviews contracted Medical Group’s referral requests for medical necessity.  Consideration is given to the appropriateness of the setting, place of service, health plan’s benefits and criteria of the requested services and utilizes service matrix for contracted providers.  Documents process in authorization system
• Ensures the denial reason is documented at an appropriate level of specificity and is easily understandable
• Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial
• Selects the correct level of hierarchy and applied correctly based on the medical information available
• Provides relevant clinical information to the request and the criteria used for decision-making
• Ensures the validity of denials of member and provider authorization requests for retrospective services
• Maintains required turnaround time (TAT) for processing denials and appeals based on federal and state guidelines
• Extrapolates and summarizes medical information and documents findings in relevant tracking system for both denials and appeals. Reviews medical records, notes, and/or detailed billing information as appropriate for appeals responses
• Interact with physicians, health plans, physician office staff, and others as needed to complete the denial and appeal processes
• Serve as a liaison between internal departments and external providers as required
• Functions as the department’s subject matter expert regarding the denial and appeal process
• Maintains confidentiality of all patient health information (PHI) in compliance with state and federal law and policy

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:

• Graduation from an accredited school of nursing
• Active, unrestricted RN Nurse license through the State of California
• 1+ year of UM/QI in a healthcare setting, or 1+ year experience in an acute care or ambulatory care setting
• Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)
• Solid knowledge of Microsoft Office
• Knowledge of Medicare, DMHC, NCQA, Milliman Care and Health Plan Guidelines

Preferred Qualifications:

• Bachelor of Science in Nursing, BSN
• 2+ or more years of UM/QI and acute care experience in a managed care environment

*All employees working remotely 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 $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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.    

OptumCare 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.

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