UnitedHealth Group Clinical Claims Review RN - Las Vegas, NV in Las Vegas, Nevada
There's an energy and excitement here, a shared mission to improve the lives of others as well as our own.
Nursing here isn't for everybody.
Instead of seeing a handful of patients each day, your work may affect millions for years to come.
Ready for a new path? Start doing your life's best work.(sm) Under direct supervision of the Manager, Clinical Claims Review (Medical Adjudication) conducts retrospective claims review for medical necessity of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services utilizing standardized criteria, protocols, and guidelines.
Works closely with the Medical Director and works on various projects as assigned.
This RN will also train and provide coverage for the Appeals and Grievances RNs in Clinical Claims Review Primary Responsibilities Maintaining pended claims, electronic inquiries and medical records work queue in order to review assigned claims (e.g.
ER, inpatient, diagnostic procedures, lab testing) to evaluate medical necessity and determine appropriate levels of care Preparation of claims for medical director review through completion of worksheets and provision of all pertinent medical information Meeting company/department standards for timeliness of review and release of claims, and for the accuracy of medical decisions.
Timeliness of reviews must be consistent with regulatory standards for production and turnaround Providing expertise in company coverage guidelines, State, CMS, NCQA as it relates to clinical appeals Providing support to all units within CR&R and Claims to ensure Star Ratings are not jeopardized and all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities Performing all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines Required Qualifications: Registered Nurse with active unrestricted license in the State of Nevada 5+ years nursing experience in utilization review, case management, clinical claims review and or a background working in a hospital or clinical setting Solid computer proficiency Preferred Qualifications: Bachelor's Degree Knowledge of managed care delivery system concepts such as HMO/ PPO Knowledge of evidenced based and standardized criteria such as Milliman Care guidelines Knowledge of CPT, and ICD-10 coding.
Broad knowledge of management of medical conditions and procedures Must demonstrate knowledge of or ability to learn and apply job functions as it relates to state, federal laws and regulations applicable to the operating unit Ability to do retrospective utilization reviews using standard criteria, protocols and guidelines Careers at UnitedHealthcare Employer & Individual.
We all want to make a difference with the work we do.
Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine.
Here, you get that opportunity every day.
As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives.
You'll help write the next chapter in the history of health care.
And you'll find a wealth of open doors and career paths that will take you as far as you want to go.
This is your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace.
Candidates are required to pass a drug test before beginning employment. Job Keywords: RN, claims, clinical claims review, claims review, appeals, grievances, medical adjudication, prior authorizations, utilization review, utilization management, case management, claims adjudication, Milliman Care guidelines, MCG, CPT, ICD-10, Las Vegas, NV 75407c12-3c5b-4e9f-b2db-243b65d53bc0
Clinical Claims Review RN - Las Vegas, NV Nevada-Las Vegas 731331