Claims Review Nurse

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Claims Review Nurse

San Diego, California

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Caring. Connecting. Growing together. With these values to guide us, our people are committed to making a meaningful difference in the lives of those we are honored to serve.

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Claims Review Nurse

Requisition number: 2376231

Job category: Nursing

Primary location: San Diego, California

Date posted: 07/24/2026

Overtime status: Non-exempt

Travel: No

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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 to start Caring. Connecting. Growing together. Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California, to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.  The Claims Review Nurse will perform the clinical review of the formal appeal and provider disputes process to ensure the resolution of appeals is consistent with organizational policies and procedures and compliant with state and federal guidelines. Must understand complex medical and regulatory issues for outpatient and inpatient areas to manage the denial through multiple levels of appeal processes involving medical directors at the group and health plan level, as well as representatives from state and federal review regulatory bodies, members, and administrative law judges. Must have a solid command of medicine, medical terminology and comprehensive writing skills