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- Phoenix, AZ
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Facility Clinical Investigator RN - US Telecommute
UnitedHealth Group • Phoenix, AZ
Posted 15 days ago
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 6 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.
- 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 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
- Will be working in a high volume production environment that is matrix drive
- High School Diploma / GED (or higher)
- Unrestricted RN (registered nurse)
- 1+ year of medical coding experience
- Must be competent in ICD - 10 and PCS
- Ability to work Monday through Friday, 8:00 am to 5:00 pm Central Time
- RHIT (registered health information technician), RHIA (registered health information administrator), CDIP (certified documentation improvement practitioner) OR current certified facility in - patient coder
- 1+ year of DRG coding or DRG auditing experience (facility only)
- Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry
- Healthcare claims experience
- Managed care experience
- Investigation and / or auditing experience
- Knowledge of health insurance business, industry terminology, and regulatory guidelines
- Ability to use a Windows PC with the ability to utilize multiple applications at the same time
- Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer
- Have a secluded office area in which to perform job duties during the work day
- Have high - speed internet access
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: DRG, coding, medical coding, RN, registered nurse, nurse, ICD-10, PCS, procedural coding, investigation, facility, in-patient, audit, DRG coding, DRG auditing, validation, coder, research