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Clinical Claims Review RN Manager - Las Vegas, NV

For those who want to invent the future of health care, here's your
opportunity. We're going beyond basic care to health programs integrated across
the entire continuum of care. Join us and help people live healthier lives
while doing your life's best work.(sm)


As the Clinical Claims Review RN
Manager you will be responsible for the management and oversight of the
Medical Adjudication, Appeals & Grievances, and Coding & Reimbursement
Units in Clinical Claims Review. 


Primary Responsibilities:

  • Identify
    and implement business priorities and 
    processes to triage, assign 
    and successfully complete work
  • Set
    priorities for each team to ensure department goals are met
  • Provide
    support to all units within CR&R and Claims to ensure all clinical
    components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and
    Federal entities
  • 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 requirements
  • Make
    assignments to licensed staff as appropriate within their Scope of
  • Participate
    in various special projects as assigned
  • Attend
    assigned meetings relating to clinical reviews and other aspects of job
  • Perform
    all job functions with a high degree of discretion and confidentiality in
    compliance with federal, company & departmental confidentiality

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:

  • Registered
    Nurse with active unrestricted license in the State of Nevada
  • 5+ years
    of nursing experience in utilization review, case management, clinical
    claims review or similar field with at least one year experience working
    in a hospital or clinical setting
  • 3+ years managerial/supervisory
  • Intermediate
    level of proficiency using a PC in a Windows environment, including
    Microsoft Word and Excel

Preferred Qualifications:

  • Bachelor’s
  • CPC
  • Knowledge
    of managed care delivery system concepts such as HMO/PPO/EPO/POS
  • 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)




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: RN, Registered Nurse,
Health Education, Clinical Review, Manager, Supervisor, Leadership, Quality
Improvement, Process Improvement, Performance Improvement, Auditing, Health
Care Analytics, Managed Care, Healthcare, CPT, ICD-10, MCG, Milliman, Las
Vegas, NV, Nevada, UHG, UHC, UnitedHealthcare

Clinical Claims Review RN Manager - Las Vegas, NV

Las Vegas, NV
Full Time

Published on 02/20/2020