Optum
RN Senior Clinical Consultant Audit/Recovery Payment Integrity
Optum, San Antonio, Texas, United States, 78208
RN Senior Clinical Consultant Audit/Recovery Payment Integrity
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 to start
Caring. Connecting. Growing together.The
Sr. Clinical Consultant - Payment Integrity
position is responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical documentation, and published CMS, Coding and other industry criteria. This position will provide direction and guidance to Medical Coding Analysts, as well as cross-functional team members within Payment Integrity and Claims. Responsible for communication with medical professionals and written education material to support improved documentation and correct coding in future.If you have a Compact License, you will have the flexibility to work remotely* as you take on some tough challenges.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, medical necessity, 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.Conduct extensive audits on a project basis: generate response letter for review by medical director(s). Monitor action plan as a result of the audit - responsible for tracking and documenting the whole process.Positions in this function perform comprehensive research and identify billing abnormalities, questionable billing practices, and/or irregularities.Investigate, research, and analyze claims data applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive billing activity.Work with Payment Integrity Analytics to determine audit sample and if a statistical extrapolation is possible what is that audit size.Conduct audits of provider records, and claims submissions to ensure appropriateness of billing practices and application of medical policy.Identify and document fraudulent or erroneous activity during an audit.Determine actual overpayment that may have occurred. Generates written notice to providers on audit findings and works with claims and legal to obtain overpayment.Participate in case review and medical determination conference/consults.Conduct reviews for medical necessity and determination of correct coding.Facilitate improvement in overall quality, completeness, and accuracy of medical record documentation.Coordinate education related to compliance, coding, and clinical documentation for payment integrity issues within the healthcare organization.Act as a consultant to claims coding professionals when additional information or documentation is needed to assign coded data.Take ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction.FWAE detection and identification of aberrant behavior for providers and facilities.Identify updated clinical analytics opportunities and participate in projects as necessary by client/other departments.Maintain and manage case review assignments.Ensure issues are identified, tracked, reported and resolved.Develop relevant training programs, policies and procedures, and resources that enable the claims and benefit load staff to process and perform job duties with accurate and timely information.Review and edit requirements, specifications, business processes and recommendations related to proposed solutions and write business rules to support benefit and claims functions.Work directly with management teams on quality results, trending analysis and needed process improvement.Escalate issues to project team and management for support and/or guidance.Keep abreast of current Medicare guidelines and Regulations and compliance standards by reviewing all updates/bulletins and changes.Modify the system specifications as changes in regulation occur.Performs other duties as assigned.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:Bachelor's degree in Nursing (Associate's degree or Nursing Diploma from accredited nursing school with 2+ years of additional experience may be substituted in lieu of a bachelor's degree) and current RN license in good standing.4+ years of ICD-9, ICD10 coding experience and medical review of Medicare claims and medical documentation with medical chart review experience.4+ years associated business experience with Medicare policies and regulations.Solid knowledge of the Medicare policies, CMS NCDs, LCDs and Articles.Preferred Qualifications:CPC certification from the American Academy of Professional Coders.5+ years in a Medicare Insurance environment.Experience working as medical review nurse and coder with solid analytical and research skills.Experience in working in a MAC or RAC with medical review and payment integrity functions.Experience working with process improvement teams and streamlining processes as required and improving departmental efficiencies.Experience with Encoder Pro.MS Office Suite, proven moderate to advanced EXCEL and PowerPoint skills.Proven ability to solve process problems crossing multiple functional areas and business units.Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action.Proven good business acumen, especially as it relates to Medicare.*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only:
The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.Application Deadline:
This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.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 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.OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
#J-18808-Ljbffr
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 to start
Caring. Connecting. Growing together.The
Sr. Clinical Consultant - Payment Integrity
position is responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical documentation, and published CMS, Coding and other industry criteria. This position will provide direction and guidance to Medical Coding Analysts, as well as cross-functional team members within Payment Integrity and Claims. Responsible for communication with medical professionals and written education material to support improved documentation and correct coding in future.If you have a Compact License, you will have the flexibility to work remotely* as you take on some tough challenges.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, medical necessity, 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.Conduct extensive audits on a project basis: generate response letter for review by medical director(s). Monitor action plan as a result of the audit - responsible for tracking and documenting the whole process.Positions in this function perform comprehensive research and identify billing abnormalities, questionable billing practices, and/or irregularities.Investigate, research, and analyze claims data applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive billing activity.Work with Payment Integrity Analytics to determine audit sample and if a statistical extrapolation is possible what is that audit size.Conduct audits of provider records, and claims submissions to ensure appropriateness of billing practices and application of medical policy.Identify and document fraudulent or erroneous activity during an audit.Determine actual overpayment that may have occurred. Generates written notice to providers on audit findings and works with claims and legal to obtain overpayment.Participate in case review and medical determination conference/consults.Conduct reviews for medical necessity and determination of correct coding.Facilitate improvement in overall quality, completeness, and accuracy of medical record documentation.Coordinate education related to compliance, coding, and clinical documentation for payment integrity issues within the healthcare organization.Act as a consultant to claims coding professionals when additional information or documentation is needed to assign coded data.Take ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction.FWAE detection and identification of aberrant behavior for providers and facilities.Identify updated clinical analytics opportunities and participate in projects as necessary by client/other departments.Maintain and manage case review assignments.Ensure issues are identified, tracked, reported and resolved.Develop relevant training programs, policies and procedures, and resources that enable the claims and benefit load staff to process and perform job duties with accurate and timely information.Review and edit requirements, specifications, business processes and recommendations related to proposed solutions and write business rules to support benefit and claims functions.Work directly with management teams on quality results, trending analysis and needed process improvement.Escalate issues to project team and management for support and/or guidance.Keep abreast of current Medicare guidelines and Regulations and compliance standards by reviewing all updates/bulletins and changes.Modify the system specifications as changes in regulation occur.Performs other duties as assigned.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:Bachelor's degree in Nursing (Associate's degree or Nursing Diploma from accredited nursing school with 2+ years of additional experience may be substituted in lieu of a bachelor's degree) and current RN license in good standing.4+ years of ICD-9, ICD10 coding experience and medical review of Medicare claims and medical documentation with medical chart review experience.4+ years associated business experience with Medicare policies and regulations.Solid knowledge of the Medicare policies, CMS NCDs, LCDs and Articles.Preferred Qualifications:CPC certification from the American Academy of Professional Coders.5+ years in a Medicare Insurance environment.Experience working as medical review nurse and coder with solid analytical and research skills.Experience in working in a MAC or RAC with medical review and payment integrity functions.Experience working with process improvement teams and streamlining processes as required and improving departmental efficiencies.Experience with Encoder Pro.MS Office Suite, proven moderate to advanced EXCEL and PowerPoint skills.Proven ability to solve process problems crossing multiple functional areas and business units.Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action.Proven good business acumen, especially as it relates to Medicare.*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only:
The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.Application Deadline:
This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.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 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.OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
#J-18808-Ljbffr