SR Clinical Consultant Audit/Recovery Payment Integrity

Sr. Clinical Consultant - Payment Integrity

Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Join us and discover the meaning behind Caring. Connecting. Growing together.

The Sr. Clinical Consultant - Payment Integrity position is responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical documentation, and published CMS, Coding and other industry criteria. This position will provide direction and guidance to Medical Coding Analysts, as well as cross-functional team members within Payment Integrity and Claims. Responsible for communication with medical professionals and written education material to support improved documentation and correct coding in future.

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

Primary Responsibilities:

• Investigate, review, and provide clinical and/or coding expertise in review of post-service, pre-payment or post payment claims, which requires interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies, medical necessity, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make pay/deny or payment recommendation decisions based on findings; this could include Medical Director/physician consultations and working independently while making their decisions
• Conduct extensive audits on a project basis: generate response letter for review by medical director(s). Monitor action plan as a result of the audit - responsible for tracking and documenting the whole process
• Positions in this function perform comprehensive research and identify billing abnormalities, questionable billing practices, and/or irregularities
• Investigate, research, and analyze claims data applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive billing activity
• Work with Payment Integrity Analytics to determine audit sample and if a statistical extrapolation is possible what is that audit size
• Conduct audits of provider records, and claims submissions to ensure appropriateness of billing practices and application of medical policy
• Identify and document fraudulent or erroneous activity during an audit
• Determine actual overpayment that may have occurred. Generates written notice to providers on audit findings and works with claims and legal to obtain overpayment
• Participate in case review and medical determination conference/consults
• Conduct reviews for medical necessity and determination of correct coding
• Facilitate improvement in overall quality, completeness, and accuracy of medical record documentation
• Coordinate education related to compliance, coding, and clinical documentation for payment integrity issues within the healthcare organization
• Act as a consultant to claims coding professionals when additional information or documentation is needed to assign coded data
• Take ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
• FWAE detection and identification of aberrant behavior for providers and facilities
• Identify updated clinical analytics opportunities and participate in projects as necessary by client/other departments
• Maintain and manage case review assignments
• Ensure issues are identified, tracked, reported and resolved
• Develop relevant training programs, policies and procedures, and resources that enable the claims and benefit load staff to process and perform job duties with accurate and timely information
• Review and edit requirements, specifications, business processes and recommendations related to proposed solutions and write business rules to support benefit and claims functions
• Work directly with management teams on quality results, trending analysis and needed process improvement
• Escalate issues to project team and management for support and/or guidance
• Keep abreast of current Medicare guidelines and Regulations and compliance standards by reviewing all updates/bulletins and changes
• Modify the system specifications as changes in regulation occur
• Performs other duties as assigned

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:

• Bachelor's Degree in Nursing required (Associate's Degree or Nursing Diploma from accredited nursing school with 2 or more years of additional experience may be substituted in lieu of a bachelor's degree) and current RN license in good standing
• 4+ years of ICD-9, ICD10 coding experience and medical review of Medicare claims and medical documentation with medical chart review experience
• 4+ years associated business experience with Medicare policies and regulations
• Solid knowledge of the Medicare policies, CMS NCDs, LCDs and Articles

Preferred Qualifications:

• CPC certification from the American Academy of Professional Coders
• 5+ years in a Medicare Insurance environment
• Experience working as medical review nurse and coder with strong analytical and research skills
• Experience in working in a MAC or RAC with medical review and payment integrity functions
• Experience working with process improvement teams and streamlining processes as required and improving departmental efficiencies
• Experience with Encoder Pro
• Proven excellent written and verbal communication skills
• Proven ability to solve process problems crossing multiple functional areas and business units
• Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
• Proven good business acumen, especially as it relates to Medicare
• MS Office Suite, moderate to advanced EXCEL and PowerPoint skills

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 $72,800 - $130,000 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 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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and 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.

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