IRR Clinical Claim Review RN
About the role
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 IRR Clinical Claim Review Nurse performs claim reviews to verify correct coding and correct charges. The clinical reviewer is responsible for documenting, researching state and federal guidelines and following internal procedures to determine the viability of the claim for further review in a production environment. Employees in this position receive limited supervision within a broad framework of policies and procedures and 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.
Responsibilities
- Perform clinical review of professional or facility claims vs. medical records to determine if the claim is supported or unsupported
- Maintain standards for productivity and accuracy. Standards are defined by the department
- Complete analysis of billing and departmental guidelines