Clinical Claim Review Nurse - National Remote

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.

The Clinical Review Clinician serves as a subject matter expert for itemized bill reviews and analyzing hospital facility bills. The clinical reviewer is responsible for documenting, researching and identifying adjustments for payment as part of a team that contributes to the preparation of Forensic Reviews for specific clients. Employees in this position receive limited supervision within a broad framework of policies and procedures. Employees in this position possess a comprehensive understanding of the claim review process including clinical claim review, medical record review, and a broad knowledge of applicable processes, procedures and billing guidelines. You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Conduct Forensic Reviews using independent clinical knowledge to compare and analyze charge details of various amounts of total billed charges to determine benefit of full clinical review and estimation of adjustments for the purpose of meeting Optum’s core business operations Complete analysis of billing and departmental guidelines Participate as needed in the achievement and completion of department goals Complete focused review of medical records to evaluate clinical course of care as applicable Assists with resolution of claims as needed to support negotiations and appeals process Interacts with internal business partners as requested Maintains appropriate documentation on all claims according to departmental guidelines and procedures Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work Other: Research and Special Projects: Perform research to support audit adjustments and resolve issues Research reference materials for clinical standards as appropriate Perform research to identify new adjustments and business rules for the goal of meeting core business operations Review and respond to research inquiries from team members and complete special research projects Participate in department and company meetings as requested