For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.
Join Optum Serve as a Senior Payment Integrity Clinical Review Specialist . Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. We help our clients and the communities they serve prevent, prepare for, respond to, and recover from emergencies and long-term public health challenges. Optum Serve's Technology Services business unit focuses on health information technology and how to further federal customers' missions by continually looking for ways to increase efficiency and thereby, lower costs.
With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Senior Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Join Optum Serve's Technology Services team to help protect our nation's most critical federal programs.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
Collaborate with a team that is triaging, investigating and medical reviewing instances of health care fraud and/or abusive conduct
Conduct provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation including preparation of written and verbal case summaries with recommendations for further actions
Perform clinical review of medical record and claims data for PI cases
Perform clinical review of PI cases in which an allegation of Fraud Waste or Abuse has been identified in accordance with all State and Federal mandated regulations/guidelines
Assess investigative and medical review findings, and/or other claims data to determine patterns and detect potential fraud, waste and abuse
Perform accurate claim decision coverage determinations based on applicable VA coverage policies and payment rules, coding guidelines, Medicare and Medicaid National and Local Coverage Determinations, utilization/practice guidelines, and clinical review judgment
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:
Active, unrestricted RN license in state of residence
5+ years of experience in a position processing medical claim, auditing, payment integrity, and/or investigating fraud for both professional and facility claims (health care fraud investigations experience preferred)
3+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment
3+ years of clinical medical/surgical experience
2+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity
Preferred Qualifications:
Certified Coding Specialist and/or Certified Inpatient Coder
Certified Fraud Examiner
Experience training and coaching other team members
An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance)
Experience with Facets, iDRS, CSP, Macess, or other claims processing systems
Experience with data analytics creating analytics
Experience with creating job aides
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $88,000 to $173,200 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
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.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
