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Commercial Clinical Investigator - Eden Prairie, MN or Franklin, TN
| Hours | Full-time, Part-time |
|---|---|
| Location | Eden Prairie, MN Eden Prairie, Minnesota |
About this job
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 & Performance.
As a vital member of the UnitedHealth Group family, we serve customers in every segment of the health care field. This includes government agencies, pharmaceutical companies, hospitals and health delivery networks, insurance providers and, of course, the diverse business divisions of UnitedHealth Group.
Bring your talent to an industry leader with the information, technology, and consulting expertise to help transform health and human services. No matter what your role, you'll be empowered to ask more questions, develop better solutions and help make the health care system greater than ever.
The Commercial Clinical investigator works on a team of 12 individuals and will serve as a clinical resource and provide clinical expertise for review of medical records and supporting documentation against submitted claims.
Primary Responsibilities:
- Perform clinical coverage review of post-service, prepayment and postpayment claims with aberrant billing patterns.
- Adherence to state, federal, client/contract compliance policies, and reimbursement policies.
- Interpretation of state and federal mandates, applicable benefit language, medical policies, reimbursement policies, and coding requirements.
- Performs clinical coding review utilizing relevant clinical information to ensure accuracy of medical coding and employs clinical expertise and judgment to determine correct coding and billing.
- Identifies aberrant billing patterns and trends, evidence of fraud, waste, abuse, or error and recommends providers to be flagged for review.
- Maintains and manages daily case review assignments, with a high emphasis on quality and documents findings with the investigations case tracking system.
- Investigative management - collaborates with entire investigative team and provides clinical support and expertise to the other investigative and analytical areas.
- Consult with Medical Director and other clinical resources, as necessary.
- Participates in provider/client/network meetings, which may include provider education through written communication.
- Include complex decision making that maximizes investigation opportunities for our clients.
Requirements
- High School Diploma or GED is required.
- Ability to work core business hours and work overtime as business needs require.
- Must be a Registered/Licensed Practical Nurse with a current, unrestricted license OR Certified Coder with 1+ years of coding experience.
- Basic ability utilizing Microsoft Word, Excel, Access and Outlook and ability to navigate a Windows environment, Microsoft One Note, and conduct Internet searches.
- Have the flexibility to be cross-trained and able to work post-pay and/or pre-pay on any given day
- CPT/ICD-9 or ICD-10 Coding experience with a thorough knowledge of health insurance business, including knowledge of industry terminology, and regulatory guidelines
Assets:
- Previous payment integrity experience, including but not limited to Fraud, Waste, Abuse, Error (FWAE), and subrogation experience
- Medical review experience
- Healthcare claims experience
- Background in conducting clinical auditing, claims research and analysis
- CPC coding certification
- Comprehensive knowledge of health insurance business, including knowledge of industry terminology, and regulatory guidelines
Soft Skills:
- Strong written and verbal communication skills.
- Strong interpersonal skills
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
At Optum, you will perform within an innovative culture that's focused on transformational change in the Healthcare system. You will leverage your skills across a diverse and multifaceted business. And you will make contributions that will have an impact that's greater than you've ever imagined.
Diversity creates a healthier atmosphere: 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.
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