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Sr. Clinical Claim Review

Company: Optum
Location: Tacoma
Posted on: November 21, 2020

Job Description:

Sr. CCR Clinical Claim Review RNOptumCare--is a network of health care providers in local markets whose mission is to help providers deliver the most effective and compassionate care to each patient they serve. OptumCare's primary focus is on doing the right things for patients, physicians, and the community. It uses an innovative service model focused on measuring what matters and increasing efficiency and performance while providing the highest level of customer service. This model allows OC to make a difference each day by delivering highly personal, customized care management to its patients.OptumCare is succeeding at helping people live healthier lives by taking a different approach to health care. OC uses a commonsense approach, focused on avoiding jargon, finding more efficient ways to operate, and providing great, in-the-moment service. We provide that service by making sure serving our patients and providers is always the first priority. Each department works from the same central idea: "How does this affect the service we provide?" Because of the extreme commitment to service, OC focuses on recruiting passionate employees who will take advantage of being empowered to provide the highest level of service at each and every step.The--OptumCare Clinical Claim Review (CCR)--team conducts medical necessity reviews for post-service professional claims and retro, first and second level reconsideration reviews for the medical necessity of inpatient versus observation level of care. This role is responsible for team lead duties related to the retrospective review of medical claims and application of medical and reimbursement policies. The OptumCare Sr. Clinical Claim Review RN requires the ability to efficiently move between review types as needed. Strong knowledge of claims processing and utilization management is preferred.Primary Responsibilities:

  • Assist Managers and Supervisors with escalated issues
  • Fields questions and serves as a resource for Clinicians and non-clinicians
  • Reviews and updates job aids to maximize quality and productivity
  • Subject Matter Expert (SME): staff resource for complex issues and process / application questions
  • Subject Matter Expert (SME): Process documents (SOP, JA, Review Guides, Policy, Procedure)
  • Actively participate in projects and meetings to champion business standardization and flawless execution
  • Supervisor coverage back up
  • Mentoring, coaching, staff education: time management, skill, processes, professional development, etc.
  • Strong communication, presentation and writing skills
  • Excellent interpersonal and motivational skills
  • Able to work independently and make sound decisions in a fast-paced environment
  • Carry a partial medical necessity review caseload volume TBD by leadership; 0 - 50%
  • Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendationsRequired Qualifications:
    • Requires a current unrestricted RN licensure in applicable state
    • MCG certification, or willing to obtain within 2 years of hire
    • CMS (LCD/LCA, NCD) and MCG application experience
    • Medical claims review experience
    • Ability to type 45 Words Per Minute
    • Strong computer literacy, Microsoft Office SuitePreferred Qualifications:
      • Certified Professional Coder (CPC)
      • Utilization Management Experience
      • Claims processing experience

Keywords: Optum, Tacoma , Sr. Clinical Claim Review, Healthcare , Tacoma, Washington

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