Clinical Documentation Improvement Specialist

Requisition number: 2382108

Job category: Medical & Clinical Operations

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

This position is full time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00 am - 5:00 pm CST. It may be necessary, given the business need, to work occasional overtime.

We offer weeks of on-the-job training. The hours of training will be aligned with your schedule.

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

Primary Responsibilities:

• Perform DRG validation reviews and confirm appropriate diagnosis related group (DRG) assignments.

• Maintains current working knowledge if ICD-10 coding principles and CMS regulations.

• Investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical records review.

• Serve as a Subject Matter Expert (SME), performing medical record reviews to include quality audits, as well as validation of accuracy and completeness of all coding elements, and medical necessity reviews.

• Responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development.

• Serves cross-functionally with Medical Directors, and sometimes Utilization Management, as well as other internal teams to assist in identification of overpayments.

• Serves as a SME for all Payment Integrity functions to include both Retrospective Data Mining, as well as Pre-Payment Cost Avoidance.

• Identifies trends and patterns with overall program and individual provider coding practices.

• Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable opportunity.

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:

• High School Diploma / GED OR equivalent work experience

• Must be 18 years of age OR older

• Certified coder with AHIMA or AAPC ex. RHIA, RHIT, CPC, CIC

• 5+ years of experience in the health insurance industry

• 2+ years of experience with health insurance claims

• 2+ years of experience with inpatient DRG coding

• 2+ years of experience with medical records review

• 2+ years of facility claims experience

• Proficiency in performing financial analysis / audits including statistical calculation and interpretation

• Ability to work Monday - Friday, during our normal business hours of 7:00 am - 5:00 pm CST.

Preferred Qualifications:

• Registered Nurse

• 2+ years of experience in Utilization Management

• Experience working with federal contracts

• CES (Claims Editing System) SME, or SME in another clinical claims editing system

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)

• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.

• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

*All employees working remotely will be required to adhere to UnitedHealth Group's 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). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. 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 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.

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.