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Clinical Claims Review RN - Las Vegas, NV

UnitedHealth Group

Las Vegas, NV
Job Code:
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Job Details

Clinical Claims Review RN - Las Vegas, NV(Job Number:707344)

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, Clinical Claim Review; conducts full and fair reviews of member and provider appeals; conducts retrospective claims review for medical necessity of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services utilizing standardized criteria, protocols, and guidelines; works closely with the Medical Director and works on various projects as assigned.


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.
  • Consider, review and evaluate claims and appeals in compliance with state and federally mandated turn- around-times and process requirements
    • Ensure that all necessary clinical information is available to allow for a full and fair review
    • Outreach as necessary to provider/provider staff for clarification or additional information needed
    • Prepare claims and case summary for MD review and appropriate decision
    • Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements
    • Access and review various resources to support denial or overturn denial (i.e. Milliman)
    • Make assignments to the A&G LPN staff as appropriate within their Scope of Practice
  • Review specific claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service
    • Prepare claims for medical director review by completing summary and attaching all pertinent medical information
    • Maintain incoming pended claims, electronic inquiries and medical records work queue
  • Attend various 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

Job Clinical Claims Review
Primary Location US-NV-Las Vegas
Other Location 
Organization E&I Nevada-Utah-Idaho
Schedule Full-time
Number of Openings 1
Apply on the Company Site

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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