Remote SCA Clinical Claim Review RN – National

Optum

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Requisition Number: 2229038
Job Category: Nursing
Primary Location: La Crosse, WI
(Remote considered)

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 diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

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.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Mountain or Pacific Time Zones preferred.

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 regard 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 (ADN or higher) in Nursing
  • Current RN license in state of residence
  • 2+ years of experience in a clinical environment as a Registered Nurse
  • 2+ years of experience working in an Electronic Medical Record system
  • Intermediate level of proficiency with the ability to use clinical judgement to interpret test results
  • Intermediate level of understanding of regulatory standards and their application to various examinations and documents
  • Intermediate level of computer proficiency including Microsoft Office programs and databases
  • Ability to work 12:00PM – 9:00PM Central Standard Time with the ability to work 1 weekend day in a rotational 8-week schedule

Preferred Qualifications:

  • Knowledge or experience in regard 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 Behavioral Health, TBI, PTSD and/or working with Veterans
  • Nurse call line and/or triage line experience
  • Collaborating with providers to ensure quality patient outcomes
  • Military experience

Soft Skills:

  • Excellent verbal and written communication skills
  • Analytical thinking and teamwork skills
  • Ability to perform detailed work with a high degree of accuracy

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

California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, Hawaii or Washington Residents Only:  The hourly range for California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, or Washington residents is $28.03 to $54.95 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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.