RN Clinical Reviewer (CPC Medical Coding Academy)

About the role

Optum is seeking a Registered Nurse with coding expertise to join its Clinical Review team in San Juan, PR. The RN Clinical Reviewer will evaluate professional and facility claims against medical records, ensuring compliance with state, federal, and contractual guidelines while supporting health‑plan reimbursement.

Key responsibilities

• Perform clinical case reviews (approximately 75% of time) to determine claim support.
• Maintain productivity and accuracy standards set by the department.
• Provide clear clinical logic to providers when needed.
• Investigate, recover, and resolve various claim types for health plans, commercial customers, and government entities.
• Ensure adherence to compliance policies, reimbursement rules, and data security.
• Participate in internal meetings and offer feedback to improve departmental processes (15%).
• Complete required continuing education and maintain coding or nursing certifications (10%).

Required profile

• Registered Nurse license in Puerto Rico or equivalent.
• Relevant coding certifications (CPC, CPC A, CIC, COC, CPMA, CCS) or a Certified Professional Coder designation.
• Proficiency with Microsoft Office Suite.
• Ability to work onsite Monday‑Friday, 40 hours per week within business hours.
• Professional proficiency in English.

Required skills

• Medical coding and claim review.
• Microsoft Suite (Word, Excel, PowerPoint).
• Certified Professional Coder (CPC) and related coding certifications.

What we offer

• Comprehensive benefits and career development opportunities.
• Inclusive culture focused on diversity, equity, and inclusion.
• Potential for growth within a global health‑care organization.