Payment Integrity Clinical Review Specialist - Remote
: Job Details :

Payment Integrity Clinical Review Specialist

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.

Join Optum Serve as a Payment Integrity Clinical Review Specialist. Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. We help our clients and the communities they serve to prevent, prepare for, respond to, and recover from emergencies and long-term public health challenges. Optum Serves Technology Services business unit focuses on health information technology and how to further federal customers missions by continually looking for ways to increase efficiency and thereby, lower costs.

With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Join Optum Serves Technology Services team to help protect our nations most critical federal programs.

Youll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations
• Conduct provider claim and clinical audits, preparing clinical review summaries with recommendations and proper citations and resources
• Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse
• Support investigation and clinical discussions with federal law enforcement
• Apply industry, state, and federal regulations and guidelines
• Assess findings to detect patterns of fraud, waste, and abuse
• Make accurate claim decisions based on VA policies, payment rules, coding guidelines, and clinical judgment

Youll 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:

• Active, unrestricted RN license in state of residence
• Certified Professional Coder (CPC)
• 3+ years of experience in a position processing medical claim auditing, payment integrity, and investigating fraud, waste, and abuse
• 2+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment
• 2+ years of clinical medical/surgical experience
• 1+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity
• Proven critical thinker

Preferred Qualifications:

• Graduate Degree
• Certified Coding Specialist
• Certified Fraud Examiner
• Experience training and coaching other team members
• Experience with Facets, PGBA, or other claims processing systems
• An intermediate level of knowledge with local, state & federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance)

All employees working remotely will be required to adhere to UnitedHealth Groups Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary for this role will range from $71,200 to $127,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyoneof every race, gender, sexuality, age, location and incomedeserves the opportunity to live their healthiest life. OptumCare is an Equal Employment Opportunity employer qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.