UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

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.
 
***This role will provide you the option to telecommute 2 days per week at manager’s discretion after completion of training.***

If you are located in Las Vegas, NV, you will have the flexibility to telecommute* as you take on some tough challenges. 
 
Primary Responsibilities:

• 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..

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications: 

• Current, unrestricted RN license for the state of Nevada 
• 2+ years of nursing experience in utilization review, case management, clinical claims review, or similar field with at least one-year experience working in a hospital or clinical setting. 
• Proficiency with Microsoft Word, Excel and Outlook
• Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Preferred Qualifications:

• Bachelor’s degree
• CPC certification
• Knowledge of managed care delivery system concepts such as HMO/PPO
• Knowledge of evidenced based and standardized criteria such as MCG
• Knowledge of CPT, and ICD-10 coding
• Broad knowledge of medical conditions, procedures and management
• Ability to learn and differentiate between company products and the benefits

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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. Go further. This is your life's best work.(sm)

Nevada Residents Only: The hourly range for Nevada residents is $28.85 to $51.30. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
 
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

**PLEASE NOTE** The Sign-On Bonus is only available to external candidates.  Candidates who are currently working for a UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time, or per diem basis (“Internal Candidates”) are not eligible to receive a Sign On Bonus.

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.