Claims Review Nurse, RN - Hybrid

Optum CA is seeking a Claims Review Nurse, RN to join our team San Diego, CA. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone.

At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

Position in this function is responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision making, as it relates to the application of criteria and application of defined levels of hierarchy and composition of compliant denial notices. The Claims Review Nurse will perform the clinical review of the formal appeal process to ensure the resolution of appeals is consistent with organizational policies and procedures and compliant with state and federal guidelines. Must understand complex medical and regulatory issues for pre-service, post-services, outpatient, and inpatient areas to manage the denial through multiple levels of appeal processes involving medical directors at the group and health plan level, as well as representatives from state and federal review regulatory bodies, members, and administrative law judges. Must have a solid command of medicine, medical terminology, medical billing and coding practices, and comprehensive writing skills in order to document the denial reason at the appropriate literacy level. Must be able to do work autonomously. Also, serves as a technical subject matter expert to the team and may be assigned to work on projects that impact departmental workflows.

If you are located in San Diego, CA, you will have the flexibility to work remotely as you take on some tough challenges. Telecommuting is defined as a work arrangement in which the employee works outside the office, typically working from home, every day and may occasionally come into one of our facilities or client/customer sites for meetings, training, or events.

Primary Responsibilities:

• Consistently exhibits behavior and communication skills that demonstrate Optum's commitment to superior customer service, including quality, care and concern with each and every internal and external customer
• Reviews claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group's financial responsibilities, benefit interpretation, etc.
• Reviews contracted Medical Group's referral requests for medical necessity. Consideration is given to the appropriateness of the setting, place of service, health plan's benefits and criteria of the requested services and utilizes service matrix for contracted providers. Documents process in authorization system
• Ensures the denial reason is documented at an appropriate level of specificity and is easily understandable
• Ensures the validity of denials of provider authorization requests for retrospective services
• Maintains required turnaround time (TAT) for processing denials and appeals based on federal and state guidelines
• Extrapolates and summarizes medical information and documents findings in relevant tracking system for both denials and appeals. Request and obtain medical records, notes, and/or detailed billing information as appropriate for appeals responses
• Serve as a liaison for member service, appeals, and/or quality improvement issues with patients and others as required
• Functions as the department's subject matter expert regarding the denial and appeal process
• Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial
• Selects the correct level of hierarchy and applied correctly based on the medical information available
• Provides relevant clinical information to the request and the criteria used for decision-making
• Evaluates out-of-network and tertiary denials for accessibility within the network
• Performs a quality assurance audit on each denial prior to finalization to ensure all elements are compliant with established guidelines
• Meets or exceeds productivity targets
• Uses, protects, and discloses Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Performs additional duties as assigned