21 hours

Clinical Claims Review RN / Coder - Las Vegas, NV

UnitedHealth Group
Las Vegas, NV
  • Job Code
770622 Clinical Claims Review RN Coder Las Vegas NV

Clinical Claims Review RN / Coder - Las Vegas, NV (770622)

Position Description

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)
Under direct supervision of the Manager and Supervisors, Clinical Claims Review, conducts full and fair reviews of member and provider appeals; conducts retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services, coding levels, etc., utilizing standardized criteria, protocols, and guidelines. 
This RN will train and provide coverage for the Medical Adjudication, Appeals & Grievances, Coding Units in Clinical Claims Review.
This role requires you to be able to work from the Las Vegas, NV office.  Opportunity to telecommute after one year of service at the manager’s discretion.
Primary Responsibilities:
  • Provide support to all units within CR&R and Claims to ensure Star Ratings are not jeopardized and all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities
  • Identify business priorities and necessary processes to triage and deliver work
  • Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes
  • Consider, review and evaluate claims and appeals in compliance with state and federally mandated turn- around-times and process requirements
    1. Ensure that all necessary clinical information is available to allow for a full and fair review.
    2. Outreach as necessary to provider/provider staff for clarification or additional information needed
    3. Prepare claims and case summary for MD review and appropriate decision. 
    4. Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements
    5. Access and review various resources to support denial or overturn denial (i.e. MCG).
    6. Make assignments to the A&G LPN staff as appropriate within their Scope of Practice.
  • Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service
    1. Maintain incoming pended claims, electronic inquiries and medical records work queue.
    2. Identify information missing from clinical documentation; request additional clinical documentation as appropriate
    3. Make determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research)
    4. Prepare claims for medical director review by completing summary and attaching all pertinent medical information
  • Interpret codes and determine coding accuracy
    1. Use available resources to further interpret coding accuracy
    2. Identify relevant information needed to make clinical determination
    3. Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials)
  • Participate in various special projects as assigned
  • Attend assigned meetings relating to clinical reviews and other aspects of job function.
  • Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines
Primary Qualifications:
  • Current, unrestricted RN license for the state of Nevada
  • 5+ years nursing experience in utilization review, case management, clinical claims review or similar field with at least 1 year experience working in a hospital or clinical setting.
  • CPC certification or ability to attain the certification within one year of hire
  • Proficiency with MS Word, Excel and Outlook
Preferred Qualifications:
  • Bachelor’s degree
  • Previous coding experience strongly preferred
  • Knowledge of managed care delivery system concepts such as HMO/PPO.
  • Ability to learn and differentiate between company products and the benefits.
  • Knowledge of evidenced based and standardized criteria such as MCG.
  • Knowledge of CPT, and ICD-10 coding
  • Broad knowledge of medical conditions, procedures and management. 
Careers at UnitedHealthcare Employer & Individual. We all want to make a difference with the work we do. Sometimes we're presented with an opportunity to make a difference on a scale we couldn't imagine. Here, you get that opportunity every day. As a member of one of our elite teams, you'll provide the ideas and solutions that help nearly 25 million customers live healthier lives. You'll help write the next chapter in the history of health care. And you'll find a wealth of open doors and career paths that will take you as far as you want to go. Go further. This is your life's best work.(sm)
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.
Job Keywords:  Registered Nurse, Nurse, RN, Clinical, Claims, Clinical Claims Review, Appeals, Grievances, Coding, Medical Adjudication, Utilization Review, Utilization Management, Prior Authorizations, Case management, Claims Adjudication, Milliman Care Guidelines, MCG, CPT, ICD-10, Las Vegas, NV, Nevada, UHC, UnitedHealthcare

Job Details

  • Contest Number770622
  • Job TitleClinical Claims Review RN / Coder - Las Vegas, NV
  • Job FamilyNursing
  • Business SegmentEmployer and Individual

Job Location Information

  • Las Vegas, NV
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusNon-exempt


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Clinical Claims Review RN / Coder - Las Vegas, NV

UnitedHealth Group
Las Vegas, NV

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