Clinical Auditor - Outpatient

This position is National Remote. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, dataand resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefitsand career development opportunities. Come make an impact on the communities we serve as you help us advance health optimizationon a global scale. Join us to start Caring. Connecting. Growing together.

Investigate Optum Waste and Error stopped claims by gathering information, researching state and federal guidelines, and following internal procedure to determine the viability of the claim for further review in a production environment.

This position is full time, Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00am - 5:00pm CST. It may be necessary, given the business need, to work occasional overtime.

We offer 4 weeks of on-the-job training. The hours of training will be aligned with your schedule.

Primary Responsibilities:

• Clinical Case Reviews - 75%
  
  
  
  • Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported.
  • Maintain standards for productivity and accuracy. Standards are defined by the department.
  • Provide clear and concise clinical logic to the providers when necessary.
  • Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization.
  • Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
  • Investigate and pursue recoveries
  • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
  • Use pertinent data and facts to identify and solve a range of problems within area of expertise
  • Verify the following elements in the medical record
    
    
    
    • Accuracy of the procedure code assignment(s)
    • Accuracy of the sequencing of codes
    • Accuracy of Patient and Provider information
    
    
    
    
  
  
  
  
• Other internal customer correspondence and team needs - 15%
  
  
  
  • Attend and provide feedback during monthly meetings with assigned internal customer department.
  • Provide continuous feedback on how to improve the department relationships with internal team members and departments.
  
  
  
  
• Continuing education - 10%
  
  
  
  • Keep up required Coding Certificate and/or Nursing Licensure.
  • Complete compliance hours as required by the department.
  
  
  
  

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:

• High School Diploma/GED
• Must be 18 years OR older
• 2+ years of experience with claims auditing and researching claims information in an outpatient facility/hospital setting
• Knowledge of CMS and AMA coding rules specific to ICD-10, PCS, CPT, HCPCS
• Comprehensive understanding of hospital coding and billing techniques and revenue cycles
• Proficient with personal computers, including Microsoft Suite of products.
• Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting.
• Experience working in a production-based environment, consistently meeting performance goals and monthly business objectives.
• Certified Outpatient Coder (COC), Certified Coding Specialist (CCS), OR Certified Professional Coder (CPC), however, CPC certified candidates must obtain Certified Outpatient Coder (COC) credentials within the first six months of employment.
• Ability to work an eight-hour shift between 07:00AM - 05:00PM CST, Monday - Friday.

Preferred Qualifications:

• Presentation or policy documentation experience
• Knowledge of Medicaid/Medicare Reimbursement methodologies
• MS Access (create, edit, format, manipulate data)
• Experience working with medical claims platforms
• Working knowledge of the healthcare insurance/managed care industry.
• Working knowledge of medical terminology and claim coding.
• Knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations
• Knowledge of Inpatient coding conventions and standards, including ICD-10 coding principles, Coding Clinics, government regulations, and protocols.

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

Soft Skills:

• Strong written and verbal communications skills.
• Ability to work in a team
• Strong analytical and problem-solving skills.

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 - $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.