Claims Review Manager RN - San Diego, CA

Optum CA is seeking a Claims Review Manager RN to join our team in 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. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. 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.

Review claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group's financial responsibilities, benefit interpretation, and coverage policy. Complete claims reviews within established timeframes to maintain compliance with legislative and delegation standards. Research genetic testing claims from non-contracted laboratories for coverage appropriateness and make recommendations to the Senior Team for approval or denial. Review ad hoc reports related to medical appropriateness, chemotherapy documentation, OB claims, over/under-utilization trends, and other reports as determined by management.

We are seeking a Manager, Claims Review to join our Medical Management team. This role involves reviewing claims for medical appropriateness for payment, assessing provider claims appeals for medical necessity, authorization requirements, contractual requirements, benefit determination, and Medicare payment rules. The Manager, Claims Review will make informed decisions on claim appeals, recommending denial or payment, and ensure all claims reviews are processed within established timeframes.

This position is full-time. Employees are required to work our normal business hours of 8:00am - 5:00pm, Monday - Friday. It may be necessary, given the business need, to work occasional overtime. Employees are required to work some days onsite and some days from home.

We offer 3 - 4 weeks of on-the-job training. The hours during training will be 8:00am - 5:00pm PST, Monday - Friday.

If you are within commutable distance to the office at 6760 Top Gun ST, Suite 201 San Diego, CA, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.

Primary Responsibilities:

• 60%: Review claims for medical appropriateness for payment, including provider contract status, referral source, coding compliance, medical group's financial responsibilities, benefit interpretation, and coverage policy.
• 25%: Complete claims reviews within established timeframes to maintain compliance with legislative and delegation standards.
• 10%: Research genetic testing claims from non-contracted laboratories for coverage appropriateness and make recommendations to the Senior Team for approval or denial.
• 5%: Review ad hoc reports related to medical appropriateness, chemotherapy documentation, OB claims, over/under-utilization trends, and other reports as determined by management.
• Other duties as assigned

Additional Position Evaluation Factors

• Impact of Decisions: Ensure members receive medically appropriate services at the most cost-effective level of care and facilitate timely claims payment to providers.
• Internal/External Contacts: Interact internally with all levels of the organization and externally with physicians, physician's office staff, health plan employees, and ancillary providers.
• Supervision Given/Received: Does supervise employees. Receives general supervision from the Director, Medical Management, and exercises discretion and independent judgment on significant matters.

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:

• High School Diploma / GED
• Must be 18 years of age OR Older
• Prior experience in claims review and/or utilization management in a managed care environment
• Experience with computers and Microsoft Windows environment
• Unrestricted, active California RN License
• Ability to work our normal business hours of 8:00am - 5:00pm, Monday - Friday. It may be necessary, given the business need, to work occasional overtime

Telecommuting Requirements:

• Reside within commutable distance to the office at 6760 Top Gun ST, Suite 201 San Diego, CA
• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

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

The salary range for this role is $71,600 to $140,600 annually based on full-time employment. 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.

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.

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