Claims Review Nurse

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California, to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities.

About the role

The Claims Review Nurse will perform the clinical review of the formal appeal and provider disputes process to ensure the resolution of appeals is consistent with organizational policies and procedures and compliant with state and federal guidelines. Must understand complex medical and regulatory issues for outpatient and inpatient areas to manage the denial through multiple levels of appeal processes involving medical directors at the group and health plan level, as well as representatives from state and federal review regulatory bodies, members, and administrative law judges. Must have a solid command of medicine, medical terminology and comprehensive writing skills in order to document the denial reason at the appropriate literacy level. Must be able to work autonomously. Also, serves as a technical subject matter expert to the team and may be assigned to work on projects that impact departmental workflows. You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Responsibilities

• Consistently exhibits behavior and communication skills that demonstrate Optum's commitment to superior customer service, including quality, care and concern with each and every internal and external customer
• Reviews claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group's financial responsibilities, benefit interpretation, etc.
• Reviews contracted Medical Group's referral requests for medical necessity. Consideration is given to the appropriateness of the setting, place of service, health plan's benefits and criteria of the requested services and utilizes service matrix for contracted providers. Documents process in authorization system
• Ensures the denial reason is documented at an appropriate level of specificity and is easily understandable
• Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial
• Selects the correct level of hierarchy and applies it correctly based on the medical information available
• Provides relevant clinical information to the request and the criteria used for decision-making
• Ensures the validity of denials of member and provider authorization requests for retrospective services
• Maintains required turnaround time (TAT) for processing denials and appeals based on federal and state guidelines
• Extrapolates and summarizes medical information and documents findings in relevant tracking system for both denials and appeals. Reviews medical records, notes, and/or detailed billing information as appropriate for appeals responses
• Interacts with physicians, health plans, physician office staff, and others as needed to complete the denial and appeal processes
• Serves as a liaison between internal departments and external providers as required
• Functions as the department's subject matter expert regarding the denial and appeal process
• Maintains confidentiality of all patient health information (PHI) in compliance with state and federal law and policy

Requirements

• Graduation from an accredited school of nursing
• Active, unrestricted RN Nurse license through the State of California
• 1+ year of UM/QI in a healthcare setting, or 1+ year experience in an acute care or ambulatory care setting
• Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)
• Solid knowledge of Microsoft Office
• Knowledge of Medicare, DMHC, NCQA, Milliman Care and Health Plan Guidelines

Preferred Qualifications

• Bachelor of Science in Nursing, BSN
• 2+ or more years of UM/QI and acute care experience in a managed care environment

Benefits

In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, and certifications.