SCA Clinical Claim Review RN - National Remote at UnitedHealth Group
About the position
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 diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. In this role, you will navigate and work within our proprietary electronic medical record system to evaluate and process patient health information to determine outcomes for various types of medical and specialty exams. You will conduct a clinical review of a variety of examination documentation, test results, assessments, and information to provide a clear, comprehensive, and concise final product. Utilizing your clinical judgment, you will identify quality assurance issues and make recommendations to reconcile documentation. Collaboration with providers via the nurse call line will be essential to ensure examinations meet regulatory and contractual requirements for compensation and benefit rating purposes. You will need to possess the ability to shift focus and multitask while maintaining a professional demeanor to meet customer and provider needs. Additionally, you will identify emergent behavioral health issues and initiate intervention when necessary. The flexibility to telecommute from anywhere within the U.S. is a key aspect of this position, with a preference for candidates in the Mountain or Pacific Time Zones.
Responsibilities
?? Remain up to date with the contract requirements.
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?? Use clinical judgement to ensure a clear, comprehensive and concise exam documentation that is reflective of the patient's service level conditions and in compliance to contract requirements.
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?? Interpret and document diagnostic test results.
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?? Educate and support providers with navigating and utilizing medical history information and prior disability claims when completing the appointment paperwork.
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?? Answer calls that come into the Clinical Operations Review queue in regards to medical or specialty exams and provide exemplary service to providers with appointment questions.
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?? Identify and evaluate exam documentation that requires immediate follow up for behavioral health issues and initiate the high-risk intervention process.
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?? Complete system generated tasks to process exam documentation.
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?? Interface via telephone and e-mail with contracted providers in retrieval of required Disability Benefits Questionnaire information and provide education regarding required contractual protocol.
Requirements
?? Accredited Associate's Degree in Nursing (ADN) (or higher).
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?? Current RN license in your state of residency.
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?? 2+ years of experience in a clinical environment as a Registered Nurse.
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?? 2+ years of experience working in an Electronic Medical Record system.
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?? Intermediate level of proficiency with the ability to use clinical judgement to interpret test results.
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?? Intermediate level of understanding with regulatory standards and their application to various examinations and documents.
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?? Intermediate level of proficiency with general computer skills including Microsoft Office programs and database experience.
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?? Ability to work 12:00PM - 9:00PM Central Standard Time with the ability to work 1 weekend day in a rotational 8 week schedule.
Nice-to-haves
?? Knowledge or experience in clinical quality assurance; auditing and compliance; education of clinical staff; Clinical Documentation Improvement; clinical experience with Neurological, Cardiovascular or Respiratory units; vision testing, audio testing, reviewing dental images; ISO 9001 standards, and/or other healthcare regulatory and accreditation standards.
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?? Experience with Behavioral Health, TBI, PTSD and/or working with Veterans.
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?? Nurse call line and/or triage line experience.
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?? Collaborating with providers to ensure quality patient outcomes.
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?? Military experience.
Benefits
?? Comprehensive benefits package
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?? Incentive and recognition programs
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?? Equity stock purchase
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?? 401k contribution
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