Full-time Remote Investigator

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. The M&R Clinical Investigator is required to determine the accuracy of claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. They must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and UHC/Client by following state and government compliance guidelines, coding requirements and policies. They must confidently analyze and interpret data and medical records/documentation on a daily basis to understand historical claims activity, determine validity and demonstrate their ability to provide written communication to the provider. They are responsible to investigate, review and provide clinical and/or coding expertise in a review of pre-payment claims. The Senior Recovery Resolution Analyst must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. You'll enjoy the flexibility to telecommute from anywhere within the U.Day to Day ResponsibilitiesPerforms quality audits of clinical review cases of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environmentDetermines accuracy of medical coding/billing and payment recommendation for pre-payment claimsThis could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical informationDetermines appropriate level of service utilizing Evaluation and Management coding principlesEnsures adherence to state and federal compliance policies, reimbursement policies and contract complianceIdentifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for reviewMaintains and manages daily case review assignments, with accountability to quality, utilization and productivity standardsProvides clinical support and expertise to the other investigative and analytical areasParticipates in team and department meetingsEngages in a collaborative work environment when applicable but is also able to work independentlyServes as a clinical resource to other areas within the clinical investigative teamWork with applicable business partners to obtain additional information relevant to the clinical reviewYou'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 QualificationsHigh School Diploma or GEDCertified Coder AHIMA or AAPC Certified coder (CPC, CCS, CCS-P ) or Nurse (RN, LPN) with unrestricted and active license/certification with medical record auditing and coding/billing experience2+ years of experience as a AHIMA or AAPC Certified coder with 2+ years of CPT/HCPCS/ICD - 10/CM/PCS coding experience or Licensed nurse with medical record auditing and coding/billing experience1+ year of working in a team atmosphere in a metric driven environment including; daily production standards and quality standardsAdvanced medical record review experienceIntermediate to advanced knowledge of health insurance business, industry terminology, and regulatory guidelinesBasic to intermediate experience with Microsoft & Adobe applications (outlook, power point, word, excel, pdf)Beginner knowledge including CPT/HCPCS/Modifiers (Medical necessity and DRG review experience is not applicable to this position)Preferred QualificationsBachelor degree (or higher)Healthcare claims experience/processing experienceStrong communication skills with the ability to interpret dataExperience with Fraud Waste & Abuse or Payment IntegrityExperience with subsequent or reconsideration reviews for FWAEStrong analytical mindset working with medical terminology or coding[Internal Posting Only] 1+ year experience of UHC platforms - COSMOS, Facets, CPW, NICEMust be proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexityMust have strong computer skills with the ability to troubleshoot problemsAll Telecommuters 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). The hourly pay for this role will range from $24.00 to $43.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.Application DeadlineThis will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. 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. Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace.