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  • Minneapolis, MN

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Optum SIU Pre - Pay Clinical Investigator - Eden Prairie, MN or US Telecommute

UnitedHealth Group • Minneapolis, MN

Posted 11 days ago

Job Snapshot

Full-Time
Healthcare - Health Services
General Business, Health Care
1

Applicant

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Job Description

Position Description:
Energize your career with one of Healthcare’s fastest growing companies.  
You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it’s a dream that definitely can come true. Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.
This opportunity is with one of our most exciting business areas: Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 17 leader.
Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation and Performance.

Primary 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 claims, which requires interpretation of state and federal mandates, applicable benefit language, medical and 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.

Required Qualifications:
  • High School Diploma / GED
  • Licensed Registered Nurse (RN), Licensed Practical Nurse (LPN) or Certified Coder
  • 3+ years of nursing / coding experience (surgical, hospital, clinic settings)
  • Ability to navigate PC based software
  • CPT and ICD coding experience 
Preferred Qualifications:
  • Bachelor’s Degree or higher
  • Experience with health insurance billing / coding
  • Experience working in a FWA / SIU or Fraud investigations role
  • Experience working with Windows PC software - Microsoft Office: Microsoft Excel - (creating / managing spreadsheets, formulas, and pivot tables), Microsoft Word - (creating / managing documents)
Soft Skills:
  • Critical thinking, problem solving and analytical skills required
  • Excellent oral and written communication skills and presentation skills
  • Ability to prioritize and manage multiple tasks
  • Proven ability to work in a team setting 
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 computer
  • Service center environment with moderate noise level due to Representatives talking, computers, printers, and floor activity

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.

 
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: claims, medical claims, healthcare claims, claims processing, claims processor; office, UnitedHealth Group, UnitedHealthcare, training class, customer service representative, customer service, CSR, Data Entry, adjustments, phone support
Job ID: 2551_733138_0
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