Transplant Clinical Claims Review TCR RN – Remote

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. 

This position requires a current, unrestricted RN license and will be responsible for reviewing, researching, and completing retrospective clinical claim reviews for Commercial, M&R, C&S, and HMO products. This is complex, detailed work in a fast-paced challenging area. The RN will review, and solution claim issues for those claims that are clinically related to transplant, gene therapy, and/or clinical trials. The nurse will partner with case managers for review of authorizations related to requested services to ensure payment is based on the applicable documented risk arrangements. 

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

Primary Responsibilities:

• Reviews claims to determine relation to transplant, gene therapy, and clinical trial services
• Evaluates claims to determine risk responsibility and forwards to the appropriate business segment for adjudication
• Completes retrospective utilization management and reviews related to transplant, CAR-T, and clinical trial services when applicable
• Identifies solutions to non-standard request and problems
• Solves moderately complex problems and/or conducts moderately complex analyses
• Works with minimal guidance, seeks guidance on only the most complex tasks
• Translates concepts into practice
• Provides explanations and information to others on difficult issues
• Solid organizational and decision-making skills
• Act as a resource for others with less experience
• Application of medical and reimbursement policies within the claim adjudication process

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 in state of residence and willing to obtain RN licensure in the following states: CA, LA, NM, NV, WA, WY, and OK
• 2+ years of experience in an Acute Care (Inpatient) clinical setting
• 1+ years of experience with Transplant patients or ICU/critical care in acute care setting
• Proficient working with MS Office applications (Word, Excel, and Outlook)
• Reside in a location that can receive a UnitedHealth Group approved high speed internet connection or can leverage existing high-speed internet service

Preferred Qualifications:

• Bachelor’s degree
• Utilization Management experience
• Experience working with risk based delegated HMO plans
• Knowledge of ICD-9 and/or ICD-10 (CPT and/or HCPC) codes
• Knowledge of claim processing procedures/systems

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. 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.