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Positions 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 compliance
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.
UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.
We are committed to introducing innovative approaches, products and services that can improve personal health and promote healthier populations in local communities. Our core capabilities... in clinical care resources, information and technology uniquely enable us to meet the evolving needs of a changing health care environment as millions more Americans enter a structured system of health benefits and we help build a stronger, higher quality health system that is sustainable for the long term.
We serve our clients and consumers through two distinct platforms:
?UnitedHealthcare, which provides health care coverage and benefits services.
?Optum, which provides information and technology-enabled health services.