[Hiring] Program Integrity Clinical Compliance Auditor @UnitedHealth Group

Role Description

The Sr. Recovery Resolution Analyst will be responsible for performing compliance reviews of medical and administrative documentation to identify instances of healthcare fraud and/or wasteful and abusive conduct by health care providers who submit claims for payment. This position will utilize information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations in order to document relevant findings.

The Sr. Recovery Resolution Analyst will conduct site visits and desk audits of provider claims, and medical and administrative records, to gather and analyze all necessary information to determine whether subject adhered to state and federal compliance policies, reimbursement policies, and contract compliance. The Sr. Recovery Resolution Analyst will present and discuss audit findings with client and input information into Optum audit workflow tools and the client’s case tracking system. Where applicable, the Auditor will support appeal and fraud investigation activities.

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 Monday thru Friday 8:00 am – 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime.

We offer on the job training. The hours during training will be aligned with your schedule.

Primary Responsibilities:

• Review medical and administrative records for audit/compliance review
• Travel to provider sites up to 25% per month to collect records and engage with providers
• Present and participate in discussions with the client regarding audit observations and findings
• Collaborate with a team of 2-5 auditors to complete reviews
• Enter audit findings data and notes in online/electronic platform using Excel-based templates
• Attend and participate in dispute reviews and administrative hearings
• Demonstrated written and verbal communications skills
• Demonstrated customer service skills

Qualifications

• High School Diploma / GED or equivalent work experience
• Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts
• Must be 18 years of age OR older
• 2+ years of experience reviewing health care documentation in a clinical or administrative role
• Experience with MS Office Suite, specifically Word, PowerPoint, and Excel (including familiarity with basic formulas and data analysis)
• Must be willing to travel up to 25% within the state of Massachusetts as business needs dictate
• Must have a Valid Driver’s license
• Ability to work 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 Monday thru Friday 8:00 am – 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime

Preferred Qualifications

• Clinical or administrative experience in long term care, for example, nursing facility care delivery/administration and/or community-based LTC service programs like Home Health
• Familiarity with Medicaid program and/or billing requirements
• Working knowledge of medical terminology and claim coding with familiarity of CPT-4, HCPCs and ICD-10 code terminology
• Experience in claim processing, healthcare provider information, and healthcare billing practices
• Experience working in a remote/telecommute workspace

Telecommuting Requirements

• Reside within the state of Massachusetts
• 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

Pay and Benefits

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
• 401k contribution (all benefits are subject to eligibility requirements)

The hourly pay for this role will range from $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable.