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Sr. Clinical Claims Review RN – Telecommute

UnitedHealth Group

This is a Full-time position in Las Vegas, NV posted May 9, 2021.

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that’s improving the lives of millions. Here, innovation isn’t about another gadget, it’s about making health care data available wherever and whenever people need it, safely and reliably. There’s no room for error. Join us and start doing your life’s best work.(sm)

Tough challenges? We know a thing or two about those. When you’re on a mission to help people live healthier lives, the stakes couldn’t be higher. As a Business Analyst Consultant, you will help rewrite the future of the health care system. You’ll analyze data and deliver bold, business-savvy ideas to impact the lives of millions. Along with ground-breaking challenge, you’ll have the support and resources of a Fortune 10 company. Join us.

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

Primary Responsibilities:

  • Investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical records review
  • Serve as a Subject Matter Expert (SME), performing medical record reviews to include quality audits, as well as validation of accuracy and completeness of all coding elements, and medical necessity reviews
  • Responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development
  • Serves cross-functionally with Medical Directors, and sometimes Utilization Management, as well as other internal teams to assist in identification of overpayments
  • Serves as a SME for all Payment Integrity functions to include both Retrospective Data Mining, as well as Pre-Payment Cost Avoidance
  • Identifies trends and patterns with overall program and individual provider coding practices
  • Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable opportunity

Are you up for navigating a complex matrix of business units and teams? We share a near obsessive desire to outperform and outdo our own achievements across our entire global business landscape. It’s going to take all you’ve got to create valuable solutions to improve the health care system. 

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:

  • Registered Nurse
  • Certified Professional Coder (CPC), or willingness to obtain within 6 months from hire date
  • 5+ years of experience in the health insurance industry
  • 2+ years of experience with health insurance claims
  • 2+ years of experience with medical records review / auditing
  • 2+ years of experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc.
  • 2+ years of experience in Utilization Management
  • Proficiency in performing financial analysis / audit including statistical calculation and interpretation
  • Proficiency in various claims payment methodologies; to include capitation, fee-for-service,   DRG, percent-of-charge, and OPPS
  • Proficiency using Microsoft Office: Word, Excel (data analysis, sorting/filtering, pivot tables), PowerPoint (prepare formal presentations and training), Visio (develop workflow processes)
  • Experience with public speaking and presenting to large audiences, including Executives and Medical Directors
  • Experience interpreting provider contractual agreements
  • If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained

Preferred Qualifications:

  • Experience working with federal contracts
  • Experience with Fraud, Waste and Abuse programs and/or previous work within an SIU (Special Investigations Unit)
  • CES (Claims Editing System) SME, or SME in another clinical claims editing system

Careers 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.(sm)

 OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

 *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Colorado Residents Only: The salary range for Colorado residents is $64,800 to $116,000. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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

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

 Job Keywords: Business Analyst consultant, Telecommute, Remote, Work from Home