Clinical Claim Review RN

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth.

About the role

The Program Integrity Clinical Compliance Auditor will perform compliance reviews of medical and administrative documentation to identify instances of healthcare fraud, waste, and abusive conduct by healthcare providers who submit claims for payment. This position utilizes information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations to document relevant findings.

The Sr. Recovery Resolution Analyst will conduct site visits and desk audits of provider claims and medical/administrative records to gather and analyze information, determining adherence to state and federal compliance policies, reimbursement policies, and contract compliance. The role involves presenting audit findings to clients and inputting information into Optum audit workflow tools and the client's case tracking system. Where applicable, the Auditor will support appeal and fraud investigation activities.

This position is full-time (40 hours/week) Monday - Friday. Employees must have flexibility to work any of our 8-hour shift schedules during normal business hours of 8:00 am - 5:00 pm local time. Occasional overtime may be required. The role includes weeks of on-the-job training aligned with your schedule. This position is remote in Massachusetts with flexibility to work remotely.

Responsibilities

• Review medical and administrative records for audit/compliance review
• Travel to provider sites up to 25%/month to collect records and engage with providers
• Present and participate in discussions with clients regarding audit observations and findings
• Collaborate with a team of 2-5 auditors to complete reviews
• Enter audit findings data and notes in online/electronic platform using Excel-based templates
• Attend and participate in dispute reviews and administrative hearings

Requirements

• High School Diploma/GED or equivalent work experience
• Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts
• 2+ years of experience reviewing healthcare documentation in a clinical or administrative role
• Experience with MS Office Suite, specifically Word, PowerPoint, and Excel (including familiarity with basic formulas and data analysis)
• Ability to travel up to 25% of the time within Massachusetts
• Must have a valid driver's license
• Must be 18 years of age or older

Preferred Qualifications

• Clinical or administrative experience in long-term care, such as nursing facility care delivery/administration and/or community-based LTC service programs like Home Health
• Experience in claim processing, healthcare provider information, and healthcare billing practices
• Experience working in a remote/telecommute workspace
• Working knowledge of medical terminology and claim coding with familiarity of CPT-4, HCPCs, and ICD-10 code terminology
• Familiarity with Medicaid program and/or billing requirements

Telecommuting Requirements

• Reside within Massachusetts
• Ability to keep all company-sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Must live in a location that can receive a UnitedHealth Group-approved high-speed internet connection or leverage an existing high-speed internet service

Benefits

In addition to your salary, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The hourly pay for this role will range from $29 - $52 per hour based on full-time employment, depending on several factors including local labor markets, education, work experience, and certifications.