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Optum SIU Pre - Pay Clinical Investigator - Eden Prairie, MN or US Telecommute
UnitedHealth Group • Minneapolis, MN
Posted 11 days ago
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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 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.
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
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)
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
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.