Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
As a Clinical Investigation Analyst, you will be responsible for helping to reduce medical costs by identifying waste and error in provider billing practices. As a Clinical Investigation Analyst, you will determine the accuracy of the bill submitted by the provider to United Health group by comparing it to medical record submitted for the date of service being reviewed. You will exercise judgement / decision making on complex payment decisions that directly impact the provider and UnitedHealthcare / Client by following state and government compliance guidelines and the policies set forth by the department with a 98% accuracy rate. You will navigate all applicable claims applications (COSMOS, UNET, Facets, Pulse, etc.), and internal systems to research and work independently on making decisions on complex cases. You will analyze and interpret data and medical records / documentation on a daily basis to understand historical claims activity, determine validity, and demonstrate their ability to provide written or verbal communication to senior leadership on root cause identification.
Primary Responsibilities:
Investigate, review, and provide clinical and / or coding expertise in review of post - service, pre- payment or post payment claims, which requires interpretation of state and federal mandates, billing practices / patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make pay/deny or payment recommendation decisions based on findings; this could include Medical Director / physician consultations and working independently while making their decisions Identify overt billing trends, waste and error identification, and recommends providers to be flagged or filtered for review and works with analytics on recommendations to increase line of business savings by client Identify updated clinical analytics opportunities and participates in projects necessary by client/other departments Maintain and manage daily case review assignments, with a high emphasis on quality, with at least 98% accuracy and within client/CMS guidelines and provides clinical explanation both to the provider Participate in provider/client/network meetings, which may include provider education through written communication and participates in additional projects as needed Participate in training of new staff and serves as a clinical resource to other areas within the clinical investigative team and provides guidance and feedback to peers when applicable
This position is full-time: (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8 hour shift schedules during our normal business hours of 7:00am – 6:00pm AST. It may be necessary, given the business need, to work occasional overtime or weekends. Our office is located in the Montehiedra area in San Juan.
**ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION**
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:
Currently possess one of the following credentials: Valid, active and unrestricted RN, NP or MD license Knowledge of Microsoft Office including Word, PowerPoint, Excel, and Outlook (create/edit/save/send documents and emails) Intermediate Windows PC navigation proficiency or higher and ability to navigate in multiple systems Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)
Preferred Qualifications:
Certified Coder, such as AHIMA or AAPC Certification (CPC, CCS, CCA, RHIT, CPMA, RHIA or CDIP) NCLEX certification Experience working in a team atmosphere in a production driven environment with quality audit standards Investigational and / or auditing experience, including government and state agency auditing Experience of UHC platforms - COSMOS, Facets and CPW and / or working with medical terminology or coding Experience with Fraud, Waste & Abuse or Payment Integrity Solid medical record review experience Knowledge of health insurance business, industry terminology, and regulatory guidelines
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: 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.