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Job Details

Clinical Claims Review RN - Telecommute

La Crosse, WI, United States

Posted on
Jun 30, 2020

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The **MEMBERS ONLY**SIGN UP NOW***. family of businesses. As a Clinical Claims Review Nurse , you can put your skills and talents to work, reviewing cases with treating physicians and other health care professionals to ensure our members receive the proper health services. This is a multifaceted role that is highly rewarding as your work is helping people live healthier lives.

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

Required schedule is Monday-Friday, 10:00am-7:00pm CENTRAL TIME. Weekend responsibilities also required on a rotating basis.

Primary Responsibilities:

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
Conduct a clinical review of a variety of examination documentation, test results, assessments and information to provide a clear, comprehensive and concise final product
Utilize clinical judgement to identify quality assurance issues and make recommendations to reconcile documentation
Collaborate with providers via the nurse call line to ensure examination meets regulatory and contractual requirements for compensation and benefit rating purposes
Possess the ability to shift focus and multitask while maintaining professional demeanor to meet customer and provider needs
Identify emergent behavioral health issues and initiate intervention when necessary
Remain up to date with the contract requirements
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
Interpret and document diagnostic test results
Educate and support provider with navigating and utilizing medical history information and prior disability claims when completing the appointment paperwork
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
Identify and evaluate exam documentation that requires immediate follow up for behavioral health issues and initiate the high risk intervention process
Complete system generated tasks to process exam documentation
Interface via telephone and e-mail with contracted providers in retrieval of required Disability Benefits Questionnaire information and provide education regarding required contractual protocol
Answer calls that come into the Clinical Operations Review queue in regards to medical or specialty exams, and lab results and provide exemplary service to providers and patients with appointment questions
May flex into other assignments within Clinical Operations department utilizing nursing skills, as needed

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:

Accredited Associate's Degree in Nursing (ADN) OR Bachelor’s Degree in Nursing (BSN)
Active, unrestricted RN license in your state of residence
Minimum 3 years of experience in a clinical environment as a Registered Nurse
Position requires the ability to use clinical judgement to interpret test results
Understanding of regulatory standards and their application to various examinations and documents
Experience working in an Electronic Medical Record system
Proficient computer skills including Microsoft Office programs and database experience
Must possess excellent verbal and written communication skills
Analytical thinking and team work skills
Ability to perform detailed work with a high degree of accuracy

Preferred Qualifications:

Previous experience in an Intensive Care Unit or Emergency Room, or Behavioral Health environment
Knowledge or experience in regards to: 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
Experience with TBI, PTSD and/or working with Veterans
Nurse call line and/or triage line experience
Collaborating with providers to ensure quality patient outcomes
Knowledge of CPT and ICD10 coding and phlebotomy
Military experience

Careers with LHI. Our focus is simple. We're innovators in cost-effective health care management. And when you join our team, you'll be a partner in impacting the lives of our customers, and employees. We've joined OptumHealth, part of the **MEMBERS ONLY**SIGN UP NOW***. family of companies, and our mission is to help the health system work better for everyone. We're located on the banks of the beautiful Mississippi River in La Crosse, Wis., with a satellite office in Chicago and remote employees throughout the United States. We're supported by a national network of more than 25,000 medical and dental providers. Simply put, together we work toward a healthier tomorrow for everyone. Our team members are selected for their dedication and mission-driven focus. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

*All Telecommuters will be required to adhere to **MEMBERS ONLY**SIGN UP NOW***.’s Telecommuter Policy.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Clinical Claim Review RN La Crosse, WI, Minneapolis, MN, Chicago IL, Telecommute, Telecommuter

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