Clinical Investigator - US Telecommute

Position Description: Welcome to one of the toughest and most fulfilling ways to help people, including yourself.

We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement.

Join us and start doing your life's best work.

The Clinical Investigator - US Telecommute will work with a team on researching issues to determine feasibility of reducing medical costs through prospective solutions of claim system processes and claim business rules.

Primary Responsibilities: Investigates, reviews, and provides clinical and / or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review.

This could include Medical Director / physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information.

Performs clinical coverage review of post - service claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns.

Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing.

Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review.

Maintains and manages daily case review assignments, with a high emphasis on quality.

Provides clinical support and expertise to the other investigative and analytical areas.

Participates in provider / client / network meetings, which may include provider education through written communication.

Participates in training of new staff, and serves as a clinical resource to other areas within the clinical investigative team.

Requirements: High School Diploma / GED Unrestricted RN / LPN or CPC (Certified Professional Coder) License 2+ years of current coding experience 2+ years of CPT / HCPCS / ICD - 9 / ICD - 10 coding experience with a thorough knowledge of health insurance business, including knowledge of industry terminology, and regulatory guidelines Assets: Bachelor s Degree (or higher) Healthcare Claims experience Managed care experience Investigation and / or Auditing experience 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 Careers with Optum.

Here's the idea.

We built an entire organization around one giant objective; make the health system work better for everyone.

So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve.

Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential.

For you, that means working on high performance teams against sophisticated challenges that matter.

Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.

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.

Keywords: Clinical Investigator, US Telecommute, Unrestricted RN/LPN license, certified coder coding, CPT, HCPCS, ICD-9, ICD-10, DRG, health insurance