Claims Review Nurse, RN - Hybrid Role

Overview Join Optum CA as a Claims Review Nurse, RN and become part of a transforming clinician-led care organization. We are dedicated to improving the lives of our clinicians and the patients they serve. With the support of a global organization, you will have access to clinical resources and data that empower you to enhance community health. Experience the fulfillment that comes from innovating care and assisting millions of patients across the country. Together, we can make healthcare better for everyone. Primary Responsibilities Demonstrate exceptional customer service and communication skills in every interaction. Conduct thorough reviews of claims for medical appropriateness and payment processing. Assess referral requests for medical necessity by considering various factors, including provider contracts and medical group responsibilities. Document denial reasons clearly and ensure compliance standards are met. Evaluate the validity of retrospective service denials and maintain compliance with regulatory turnaround times. Summarize medical findings and maintain accurate tracking systems for denials and appeals. Act as a liaison for member service, managing appeals and quality improvement issues. Serve as a subject matter expert on the denial and appeal processes. Confirm appropriate references and guidelines are utilized in decision-making. Assess out-of-network denials to ensure accessibility within the care network. Conduct quality assurance audits on each denial prior to finalization. Meet or exceed productivity targets on a consistent basis. Ensure compliance with HIPAA regulations regarding patient health information. Take on additional responsibilities as assigned. Required Qualifications Graduation from an accredited nursing school. Active, unrestricted RN license in California. Basic Life Support certification (AHA) or CPR/AED certification (American Red Cross). 1+ years of utilization management/quality improvement experience or relevant acute care experience. Strong knowledge of Medicare, DMHC, NCQA, and relevant health plan guidelines. Proficient in Microsoft Office tools. Preferred Qualifications Bachelor of Science in Nursing (BSN) preferred. 2+ years of utilization management/quality improvement experience in a managed care environment. *Remote employees must adhere to UnitedHealth Group's Telecommuter Policy. Compensation ranges from $28.27 to $50.48 per hour based on various factors including experience and qualifications. We offer a comprehensive benefits package and opportunities for professional growth. At UnitedHealth Group, we aim to help everyone live healthier lives. We are committed to addressing health disparities and improving outcomes for all patients, especially those from historically marginalized groups. UnitedHealth Group is an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or any protected status by law. This is a drug-free workplace. Candidates will need to pass a drug test before employment.