UnitedHealth Group
Clinical Investigation Analyst CIC (RN)- San Juan, PR - 2336469
UnitedHealth Group, San Juan, San Juan, us, 00902
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier. 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.
Primary Responsibilities:
Clinical Case Reviews -75%
Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported
Maintain standards for productivity and accuracy.Standards are defined by the department
Provide clear and concise clinical logic to the providers when necessary
Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
Investigate and pursue recoveries
Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
Use pertinent data and facts to identify and solve a range of problems within area of expertise
Other internal customer correspondence and team needs - 15%
Attend and provide feedback during monthly meetings with assigned internal customer department
Provide continuous feedback on how to improve the department relationships with internal team members and departments
Continuing education - 10%
Keep up required Coding Certificate and/or Nursing Licensure
Complete compliance hours as required by the department
ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION
You will 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:
Registered Nurse (RN), Coding Certificate or Nursing Licensure, for example:
Puerto Rico Registered Nurse
Certified Professional Coder (CPC) + CPC A
Certified Inpatient Coder (CIC)
Certified Outpatient Auditor (COC)
Certified Professional Medical Auditor (CPMA)
Certified Coding Specialist (CCS)
Experience in a hospital/inpatient setting, surgical or clinic
Proficient with computers, including Microsoft Suite of products
Willing or able to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL
Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)
Preferred Qualifications:
Experience working with medical claims platforms
Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting
Presentation or policy documentation experience
Knowledge of CMS and AMA coding rules specific to CPT, HCPCS
Knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations
Knowledge of Medicaid/Medicare Reimbursement methodologies
Working knowledge of the healthcare insurance/managed care industry
Working knowledge of medical terminology and claim coding
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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Primary Responsibilities:
Clinical Case Reviews -75%
Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported
Maintain standards for productivity and accuracy.Standards are defined by the department
Provide clear and concise clinical logic to the providers when necessary
Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
Investigate and pursue recoveries
Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
Use pertinent data and facts to identify and solve a range of problems within area of expertise
Other internal customer correspondence and team needs - 15%
Attend and provide feedback during monthly meetings with assigned internal customer department
Provide continuous feedback on how to improve the department relationships with internal team members and departments
Continuing education - 10%
Keep up required Coding Certificate and/or Nursing Licensure
Complete compliance hours as required by the department
ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION
You will 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:
Registered Nurse (RN), Coding Certificate or Nursing Licensure, for example:
Puerto Rico Registered Nurse
Certified Professional Coder (CPC) + CPC A
Certified Inpatient Coder (CIC)
Certified Outpatient Auditor (COC)
Certified Professional Medical Auditor (CPMA)
Certified Coding Specialist (CCS)
Experience in a hospital/inpatient setting, surgical or clinic
Proficient with computers, including Microsoft Suite of products
Willing or able to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL
Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)
Preferred Qualifications:
Experience working with medical claims platforms
Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting
Presentation or policy documentation experience
Knowledge of CMS and AMA coding rules specific to CPT, HCPCS
Knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations
Knowledge of Medicaid/Medicare Reimbursement methodologies
Working knowledge of the healthcare insurance/managed care industry
Working knowledge of medical terminology and claim coding
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
#J-18808-Ljbffr