Clinical Claims Review RN - Remote

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

Under direct supervision of the Manager and Supervisors, Clinical Claims Review, conducts retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services, coding levels, etc., utilizing standardized criteria, protocols, and guidelines. This RN will train and provide coverage for the Medical Adjudication and Coding Units in Clinical Claims Review. If you reside within a commutable distance from the Las Vegas, NV area, you will have the flexibility to work remotely* as you take on some tough challenges.

Provide support to all units within Claims to ensure all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities Identify business priorities and necessary processes to triage and deliver work Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service Maintain incoming pended claims, electronic inquiries and medical records work queue Identify information missing from clinical documentation; request additional clinical documentation as appropriate Make determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research) Prepare claims for medical director review by completing summary and attaching all pertinent medical information. Interpret codes and determine coding accuracy Use available resources to further interpret coding accuracy Identify relevant information needed to make clinical determination Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials) Participate in various special projects as assigned Attend assigned meetings relating to clinical reviews and other aspects of job function Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines