IRR Clinical Claim Review RN

The IRR Clinical Claim Review Nurse performs claim reviews to verify correct coding and charges, documenting and researching state and federal guidelines to determine claim viability. This role is ideal for those with a comprehensive understanding of the claim review process and a background in clinical settings.

• Location: Plymouth, MA
• Schedule: Full Time, Day shift
• Pay: $29 - $52 per hour
• Residency: Must reside in the U.S.
• Work Style: Telecommute from anywhere within the U.S.

• Perform clinical review of professional or facility claims vs. medical records.
• Maintain standards for productivity and accuracy defined by the department.
• Complete analysis of billing and departmental guidelines.
• Provide clear and concise clinical logic to clients and providers.
• Participate in the achievement and completion of department goals.
• Complete focused review of medical records to evaluate clinical course of care.
• Assist with resolution of claims to support negotiations and appeals process.
• Ensure adherence to state and federal compliance policies.
• Maintain appropriate documentation on all claims according to departmental guidelines.
• Understand and maintain HIPAA confidentiality and privacy standards.

Education:

• Associate's degree required

Experience:

• 2+ years of clinical experience within an acute care setting
• 1+ years of experience in Utilization Management, pre-authorization, claim review, appeals review, or medical record review

Licenses &

Certifications:

• Active and unrestricted RN license in the state of residence required
• Auditing and coding certifications preferred (CPC, COC, CIC, CPB, CPMA) or ability to obtain within 1 year of employment

• Paid Time Off which accrues with the first pay period plus 8 Paid Holidays
• Medical Plan options with Health Spending Account or Health Saving Account
• Dental, Vision, Life & AD&D Insurance, Short-term and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

United Health Group is a leading healthcare provider committed to delivering exceptional patient care. They focus on helping people live healthier lives and improving the health system for everyone. Their culture emphasizes inclusion, career development, and comprehensive benefits.