Program Integrity Clinical Compliance Auditor
Optum · Boston, MA · 1 mo ago
Finance$29–$52/hrFull-time
Primary 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 the client 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
Required Qualifications
- Demonstrated written and verbal communications skills
- Demonstrated customer service skills
- High School Diploma / GED OR equivalent work experience
- Must be 18 years of age OR older
- Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts
- Valid Driver's license
- 2+ years of experience reviewing health care 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 the state of Massachusetts as business needs dictate
- Ability to work full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime
Preferred Qualifications
- Clinical or administrative experience in long term care, for example, 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
- Familiarity with medical terminology and claim coding with familiarity of CPT-4, HCPCs and ICD-10 code terminology
- Familiarity with Medicaid program and/or billing requirements