Position Description:Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.SMPositions in this function are responsible for investigating, reviewing, and resolving Facility provider claims on behalf of our commercial and government customers and their health plans. This may include participation in telephone calls or meetings with providers, clients and other investigative areas. Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliancePrimary Responsibilities:Investigates, reviews, and provides clinical and / or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. This could include Medical Director / physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information.Performs clinical coverage review of post - service which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with over billing patterns.Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing.Identifies over billing patterns and trends, waste and error, and recommends providers to be flagged for review.Maintains and manages daily case review assignments, with a high emphasis on quality.Provides clinical support and expertise to the other investigative and analytical areas.Participates in provider / client / network meetings, which may include provider education through written communication.
Required Qualifications:High School Diploma / GED RN, LPN with 2+ years of current experience with an unrestricted license, OR 2+ years of experience as a Certified Coder2+ years of CPT / HCPCS / ICD - 9 / ICD - 10 coding experience with a thorough knowledge of the health insurance business, knowledge of industry terminology, and regulatory guidelinesHealthcare Claims experienceManaged Care experienceInvestigational and / or Auditing experiencePreferred Qualifications:Bachelor's Degree (or higher)Physical Requirements and Work Environment:Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computerService center environment with moderate noise level due to Representatives talking, computers, printers, and floor activityCareers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SMDiversity 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. Candidates are required to pass a drug test before beginning employment.Keywords: RN; LPN; Coding; Recovery; Resolution; Telecommute
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.