Manager Clinical Claim Review - Remote

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)

The Optum Care Clinical Claim Review team conducts retrospective, post-service clinical reviews to determine medical appropriateness of inpatient level of care as retro, first and second level reconsideration; potential preventable readmission reviews; and outpatient professional services. This role is responsible for managing a team of supervisors and is accountable for leading the overall team. A strong knowledge of claims processing, medical claim review and utilization management to lead a team of nurses in outpatient professional and inpatient level of care reviews, and effectively navigate multiple systems as needed to support the team.

You’ll enjoy the flexibility to work remotely* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Influences or provides input to forecasting and planning activities
• Solid communication, presentation and writing skills
• Resolves problems and provides guidance to direct reports, clinical and non-clinical staff
• Oversee the work activities of supervisors
• Actively lead projects and team leadership meetings
• Ability to work independently and make sound decisions in a fast-paced environment
• Collaborate with physicians, claims operations, prior authorization, utilization management, local market teams and support staff as needed
• Identify and resolve operational problems using defined processes, expertise, and clinical judgment
• Adapts departmental plans and priorities to address business and operational challenges
• Develop plans to meet short-term objectives
• Monitor individual performance of direct reports, provide monthly and annual metrics on scorecards with actionable feedback
• Set the direction of the CCR team

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:

• Proven solid attention to detail and accuracy, excellent evaluative and analytical skills
• Leadership experience
• Intermediate experience using Microsoft Office applications (Word, Excel (pivot tables), PowerPoint)
• Current unrestricted RN licensure in state of residence
• Solid knowledge of medical claims and medical necessity review processes

Preferred Qualifications:

• 2+ years of experience with data analysis
• Medicare experience
• BSN degree or related field
• 2+ years of leadership experience

Careers at OptumCare. We're on a mission to change the face of health care. As the largest health and wellness business in the US, we help 58 million people navigate the health care system, finance their health care needs and achieve their health and well-being goals. Fortunately, we have a team of the best and brightest minds on the planet to make it happen. Together we're creating the most innovative ideas and comprehensive strategies to help heal the health care system and create a brighter future for us all. Join us and learn why there is no better place to do your life's best work.(sm)

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

California, Colorado, Connecticut, Nevada, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New York, Rhode Island or Washington residents is $85,000 to $167,300. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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.

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

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: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.