M&R Clinical Investigator
About The Position
The M&R Clinical Investigator reviews pre-payment claims and medical records to determine whether provider-submitted claims are accurate. The role requires sound judgment on complex payment decisions, applying coding requirements, state and federal compliance guidelines, reimbursement policies, contract terms, benefit language, and relevant clinical information. The investigator analyzes claims history and medical documentation, makes payment recommendations, and communicates review findings in writing to providers. This position also involves managing daily case assignments and monthly performance metrics in a production-driven environment while meeting client-mandated turnaround times. The investigator identifies aberrant billing patterns and potential fraud, waste, or abuse; provides clinical and coding expertise to investigative teams; and collaborates with business partners and physicians when additional information or consultation is needed. The role is telecommutable from anywhere within the United States, subject to UnitedHealth Group’s Telecommuter Policy.
Requirements
- High school diploma or GED.
- AHIMA- or AAPC-certified coder (CPC, CCS, or CCS-P), or nurse (RN or LPN) with an unrestricted, active license or certification and medical record auditing and coding/billing experience.
- At least 2 years of experience as an AHIMA- or AAPC-certified coder, including at least 2 years of CPT/HCPCS/ICD-10-CM/PCS coding experience; alternatively, licensed nurses must have medical record auditing and coding/billing experience.
- At least 1 year of experience working in a team environment with metrics, including daily production and quality standards.
- Advanced medical record review experience.
- Intermediate to advanced knowledge of the health insurance business, industry terminology, and regulatory guidelines.
- Basic to intermediate experience with Microsoft and Adobe applications, including Outlook, PowerPoint, Word, Excel, and PDF tools.
- Beginner knowledge of CPT, HCPCS, and modifiers. Medical necessity and DRG review experience is not applicable to this position.
- Ability to navigate multiple computer systems simultaneously, troubleshoot problems, and work with varying levels of system complexity.
- Ability to manage a caseload, work independently, make decisions on complex cases, and communicate review findings in writing.
- Must pass a drug test before beginning employment.
- Telecommuters must adhere to UnitedHealth Group’s Telecommuter Policy.
Nice To Haves
- Bachelor’s degree or higher.
- Healthcare claims or claims processing experience.
- Strong communication skills and ability to interpret data.
- Experience with Fraud, Waste & Abuse or Payment Integrity.
- Experience with subsequent or reconsideration reviews for FWAE.
- Strong analytical mindset and experience working with medical terminology or coding.
- For internal applicants only: at least 1 year of experience with UHC platforms such as COSMOS, Facets, CPW, or NICE.
Responsibilities
- Perform quality audits of clinical review cases involving CPT, HCPCS, and modifiers assigned to claim codes in a telecommuting work environment.
- Determine medical coding and billing accuracy and recommend payment decisions for pre-payment claims.
- Consult with Medical Directors or physicians as needed, and interpret state and federal mandates, benefit language, medical and reimbursement policies, contract requirements, and clinical information.
- Determine appropriate levels of service using Evaluation and Management coding principles.
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract requirements.
- Identify aberrant billing patterns and trends and evidence of fraud, waste, or abuse; recommend providers for review.
- Manage daily case review assignments and meet quality, utilization, productivity, and compliance turnaround-time standards.
- Provide clinical support and expertise to investigative and analytical areas and serve as a clinical resource to the clinical investigative team.
- Work with business partners to obtain information relevant to clinical reviews.
- Participate in team and department meetings and collaborate with colleagues while also working independently.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase program.
- 401(k) contribution, subject to eligibility requirements.
- Career development opportunities.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
