Sr. Payment Integrity Clinical Review Specialist – Optum Serve – Remote in Baltimore, MD

Sr. Payment Integrity Clinical Review Specialist - Optum Serve - Remote - UnitedHealth Group - Baltimore, MD - work from home job Company: UnitedHealth Group Job description: For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm) Join Optum Serve as a Senior Payment Integrity Clinical Review Specialist. Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. With trillions of dollars spent on health care annually, in the United States, the potential for Fraud, Waste and Abuse (FWA) is staggering. Even worse, the lives of millions of patients hang in the balance. As a Senior Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. You’ll enjoy the flexibility to work remotely

• from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities: • Collaborate with a team that is triaging, investigating and medical reviewing instances of health care fraud and/or abusive conduct • Conduct provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation including preparation of written and verbal case summaries with recommendations for further actions • Perform clinical review of medical record and claims data for PI cases • Perform clinical review of PI cases in which an allegation of Fraud Waste or Abuse has been identified in accordance with all State and Federal mandated regulations/guidelines • Assess investigative and medical review findings, and/or other claims data to determine patterns and detect potential fraud, waste and abuse • Perform accurate claim decision coverage determinations based on applicable VA coverage policies and payment rules, coding guidelines, Medicare and Medicaid National and Local Coverage Determinations, utilization/practice guidelines, and clinical review judgment 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: • Active, unrestricted RN license in state of residence • 5+ years of experience in a position processing medical claim, auditing, payment integrity, and/or investigating fraud (health care fraud investigations experience preferred) • 3+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment • 3+ years of clinical medical/surgical experience • 2+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity Preferred Qualifications: • Graduate Degree • Certified Coding Specialist • Certified Fraud Examiner • Experience training and coaching other team members • Experience with Facets, iDRS, CSP, Macess, or other claims processing systems • An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance) California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $85,000 to $167,300. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives. • All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 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. Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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. OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Expected salary: $85000 - 167300 per year Location: Baltimore, MD Job date: Wed, 30 Aug 2023 22:50:45 GMT Apply for the job now! Apply Job!