Remote Clinical Claim Review RN – Multiple Locations


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Requisition Number: 2175486
Job Category: Nursing
Primary Location: Phoenix, AZ
(Remote considered)

There’s an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn’t for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life’s best work.(sm)

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.

The required hours for this position are:

Monday through Friday: 1:00pm to 10:00pm ET/12:00pm to 9:00pm CT/11:00am to 8:00pm MT/10:00am to 7:00pm PT

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

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 regarding 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
  • Experience working in an Electronic Medical Record system
  • Understanding/knowledge of regulatory standards and their application to various examinations and documents
  • Proficient computer skills including Microsoft Office programs and database experience
  • Proven excellent verbal and written communication skills
  • Proven analytical thinking and teamwork skills
  • Proven ability to perform detailed work with a high degree of accuracy
  • Proven ability to work 1:00pm to 10:00pm ET/12:00pm to 9:00pm CT/11:00am to 8:00pm MT/10:00am to 7:00pm PT
  • Distraction-free, dedicated space in home for home office
  • Access to high-speed internet (cable, fiber optic)

Preferred Qualifications:

  • Experience in an Intensive Care Unit or Emergency Room
  • Knowledge or experience in:
    • Clinical quality assurance
    • Auditing and compliance
    • Education of clinical staff
    • Clinical documentation improvement
  • Clinical experience:
    • Neurological
    • Cardiovascular or Respiratory units
    • Vision testing/Audio testing
    • Reviewing dental images
    • ISO 9001 standards
    • Healthcare regulatory and accreditation standards
  • Experience with Behavioral Health, TBI, PTSD and/or working with Veterans
  • Military experience
  • Collaborating with providers to ensure quality patient outcomes

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)

California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The hourly range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $27.07 to $53.08. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy