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- 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, pre - payment claims, 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 aberrant billing patterns.
- Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing.
- Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, 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.
- Participates in training of new staff, and serves as a clinical resource to other areas within the clinical investigative team.
- High School Diploma / GED or higher
- LPN / RN License with 2+ years of current experience with an unrestricted license, OR, 2+ years experience as a Certified Coder
- 2+ years of CPT / HCPCS / ICD - 9/ ICD - 10 coding experience with a thorough knowledge of health insurance business including industry terminology and regulatory guidelines
- Bachelor’s degree or higher in healthcare field
- Healthcare Claims / Managed Care experience
- Investigational and / or Auditing experience
- Client service
Diversity 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: Optum, coder, LPN, RN