Optum
RN Clinical Reviewer (CPC Medical Coding Academy) - San Juan, PR
Optum, San Juan, San Juan, us, 00902
RN SIU Appeals Clinical Reviewer (CPC Medical Coding Academy) - San Juan, PR
Join to apply for the
RN SIU Appeals Clinical Reviewer (CPC Medical Coding Academy) - San Juan, PR
role at
Optum
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 inclusion, talented peers, comprehensive benefits and career development opportunities.
Primary Responsibilities
Clinical Case Reviews - 75%
Perform clinical review of professional or facility claims versus medical records to determine if the claim is supported or unsupported.
Maintain standards for productivity and accuracy as defined by the department.
Provide clear and concise clinical logic to 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.
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.
Demonstrated proficiency with computers, including Microsoft Suite of products.
Willing or able to work from Monday to Friday, 40 hours per week during business operating hours of 8am - 7pm ATL.
Professional proficiency in both English and Spanish (English proficiency assessment required).
Preferred Qualifications
Experience working with medical claims platforms.
Medical record coding experience with 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 Statutes, 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 has the opportunity to live their healthiest life. We are committed to equitable care and to mitigating the impact of barriers to health for all.
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.
Referrals increase your chances of interviewing at Optum by 2x.
Get notified about new Registered Nurse jobs in San Juan, Puerto Rico.
#J-18808-Ljbffr
RN SIU Appeals Clinical Reviewer (CPC Medical Coding Academy) - San Juan, PR
role at
Optum
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 inclusion, talented peers, comprehensive benefits and career development opportunities.
Primary Responsibilities
Clinical Case Reviews - 75%
Perform clinical review of professional or facility claims versus medical records to determine if the claim is supported or unsupported.
Maintain standards for productivity and accuracy as defined by the department.
Provide clear and concise clinical logic to 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.
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.
Demonstrated proficiency with computers, including Microsoft Suite of products.
Willing or able to work from Monday to Friday, 40 hours per week during business operating hours of 8am - 7pm ATL.
Professional proficiency in both English and Spanish (English proficiency assessment required).
Preferred Qualifications
Experience working with medical claims platforms.
Medical record coding experience with 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 Statutes, 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 has the opportunity to live their healthiest life. We are committed to equitable care and to mitigating the impact of barriers to health for all.
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.
Referrals increase your chances of interviewing at Optum by 2x.
Get notified about new Registered Nurse jobs in San Juan, Puerto Rico.
#J-18808-Ljbffr