Medical Claims Review Manager – Remote

Requisition Number: 2255726
Job Category: Nursing
Primary Location: Draper, UT, US
(Remote considered)

Doctor consulting nurse at nurse station.

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. 
 

The Optum Care Medical Claim Review team conducts retrospective, post-service clinical reviews to determine medical appropriateness of inpatient level of care as retro, first and second level reconsideration; potential preventable readmission reviews; and outpatient professional services. This role is responsible for coordination, supervision and is accountable for the daily activities related to the retrospective review of medical claims and application of medical and reimbursement policies. A strong knowledge of claims processing, medical claim review and utilization management to lead a team of nurses in outpatient professional and inpatient level of care reviews, and effectively move between review types as needed to support the team.
 

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 
  

Primary Responsibilities: 

  • Supervise and coordinate daily work activities of the MCR team
  • Monitor, create reports, and set priorities for the team productivity, metrics, and quality audits to ensure established standards are met
  • Monitor individual performance of direct reports, provide monthly and annual metrics on scorecards with actionable feedback
  • Collaborate with physicians, claims operations, prior authorization, utilization management, local market teams and support staff as needed
  • Develop plans to meet short-term objectives
  • Decisions are guided by policies, procedures and business plan
  • Reviews and updates job aids to maximize quality and productivity
  • Fields questions and serves as a resource for clinical and non-clinical staff
  • Influences or provides input to forecasting and planning activities
  • Identify and resolve operational problems using defined processes, expertise, and clinical judgment
  • Actively lead projects and team leadership meetings
  • Solid communication, presentation and writing skills
  • Ability to work independently and make sound decisions in a fast-paced environment

  
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 licensure in state of residence
  • 2+ years of previous leadership experience 
  • Advanced experience using Microsoft Office applications (Word, Excel, PowerPoint)
  • Solid knowledge of medical claims and medical necessity review processes
  • Solid attention to detail and accuracy, excellent evaluative and analytical skills
Preferred Qualifications:
  • BSN degree or related field
  • 2+ years of experience with data analysis
  • Medicare experience
  
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy. 
  
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $88,000 to $173,200 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.  
  
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 
  
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.    
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. 

Additional Job Detail Information

Requisition Number 2255726

Employee Status Regular

Job Level Manager

Travel No

Country: US

Overtime Status Exempt

Schedule Full-time

Shift Day Job

Telecommuter Position Yes

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