[Hiring] Clinical Claim Review RN @UnitedHealth Group

Role Description

The Medical Coding Auditor 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. This position supports the identification of suspected Waste & Error of health insurance claims and ensures claims are accurately documented.

• Exercise judgement/decision making on complex payment decisions that directly impacts the provider and client by following state and government compliance guidelines, coding requirements and policies.
• Analyze and interpret data and medical records/documentation daily to understand historical claims activity, determine validity and provide written communication to the provider.
• Investigate, review and provide clinical and/or coding expertise in a review of claims.
• Effectively manage caseload and monthly metrics in a production driven environment.
• Ensure compliance turnaround times mandated by the client are met.
• Proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity.
• Research and work independently on making decisions on complex cases.

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

Primary Responsibilities:

• Perform clinical review of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environment.
• Determine accuracy of medical coding/billing and payment recommendation for claims.
• Consult with Medical Director/physicians, interpret state and federal mandates, applicable benefit language, medical and reimbursement policies, and consider relevant clinical information.
• Determine appropriate level of service utilizing Evaluation and Management coding principles.
• Provide detailed clinical narratives on case outcomes.
• Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance.
• Identify aberrant billing patterns and trends, evidence of fraud, waste, or abuse, and recommend providers to be flagged for review.
• Maintain and manage daily case review assignments, with accountability to quality, utilization, and productivity standards.
• Provide clinical support and expertise to other investigative and analytical areas.
• Participate in team and department meetings.
• Engage in a collaborative work environment when applicable but also able to work independently.
• Serve as a clinical resource to other areas within the clinical investigative team.
• Work with applicable business partners to obtain additional information relevant to the clinical review.

Qualifications

• Certified Coder AHIMA (CCA, CCS, CCS-P) or AAPC Certified coder (CPC, CPC-I).
• 2+ years of experience as an AHIMA or AAPC Certified coder.
• 2+ years of CPT/HCPCS/Modifiers coding experience.
• 2+ years of strong medical record review experience.
• 1+ years of working in a team atmosphere in a metric driven environment including daily production standards and quality standards.
• 1+ years of experience in the health insurance business, using industry terminology and regulatory guidelines.
• 1+ years of experience in Waste & Error principles.

Requirements

• Healthcare claims experience/processing experience.
• Experience with Fraud Waste & Abuse or Payment Integrity.
• [Internal Posting Only] 1+ year experience of UHC platforms - COSMOS, Facets, CPW, NICE, ISET, UNET.
• Proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexity.
• Strong computer skills with the ability to troubleshoot problems.
• Intermediate experience with Microsoft & Adobe applications (Outlook, Power Point, Word, Excel, OneNote, Teams, PDF).

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).
• Hourly pay for this role will range from $35 to $63 per hour based on full-time employment.

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.