Clinical Claim Review RN – Remote in New York

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

The Clinical Claim Review RN is responsible for performing clinical reviews post service utilizing established guidelines and clinical criteria along with state and federal mandates and applicable benefit language to make determinations that drive better provider and member outcomes and lower the cost of care. The Clinical Claim Review Nurse works in a fast paced, ever changing environment with a vigilant focus on improving the member and provider experience. Schedule: Monday – Friday, 7:00 – 4:00 or 8:00 -5:00 EST Location: This is a remote position, but you must reside in New York You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Perform clinical reviews, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information Function as a member of a self-directed team to meet specific individual and team performance metrics Communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations Work independently and collaboratively with Medical Directors and non-clinical partners Adapt to a highly changing environment and a heavy case load