M&R Coding Clinical Investigator

UnitedHealth Group•Plymouth, MN

3d•$24 - $43•Remote

About The Position

The M&R Coding Clinical Analyst is required to determine the accuracy of claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. They must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and UHC/Client by following state and government compliance guidelines, coding requirements and policies. They must confidently analyze and interpret data and medical records/documentation on a daily basis to understand historical claims activity, determine validity and demonstrate their ability to provide written communication to the provider. They are responsible to investigate, review and provide clinical and/or coding expertise in a review of pre-payment claims. They need to effectively manage their caseload and monthly metrics in a production driven environment and ensure they are meeting all compliance turnaround times mandated by the client. The Senior Recovery Resolution Analyst must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. They must have the ability to research and work independently on making decisions on complex cases. Remote: You’ll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.

Requirements

High School Diploma/GED
Certified Coder AHIMA or AAPC Certified coder (CPC, CCS, CCS-P) or Nurse (RN, LPN) with unrestricted and active license/certification with medical record auditing and coding/billing experience
2+ years of experience as an AHIMA or AAPC Certified coder with 2+ years of CPT/HCPCS/ICD/Modifiers – 10/CM/PCS coding experience or Licensed nurse with medical record auditing and coding/billing experience
2+ years of experience with health insurance business, industry terminology, and regulatory guidelines
1+ years of working in a team atmosphere in a metric driven environment including; daily production standards and quality standards
Intermediate level of experience with medical record review
Intermediate level of computer skills with the ability to troubleshoot problems
Basic level of experience with Microsoft & Adobe applications (outlook, power point, word, excel, pdf)
Must be proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexity

Nice To Haves

Bachelor’s degree
Healthcare claims experience/processing experience
Strong communication skills with the ability to interpret data
Experience with Fraud Waste & Abuse or Payment Integrity
Experience with subsequent or reconsideration reviews for FWAE
Strong analytical mindset working with medical terminology or coding
[Internal Posting Only] 1+ year experience of UHC platforms - COSMOS, Facets, CPW, NICE

Responsibilities

Performs quality audits of clinical review cases of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environment
Determines accuracy of medical coding/billing and payment recommendation for pre-payment claims
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
Determines appropriate level of service utilizing Evaluation and Management coding principles
Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
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 accountability to quality, utilization and productivity standards
Provides clinical support and expertise to the other investigative and analytical areas
Participates in team and department meetings
Engages in a collaborative work environment when applicable but is also able to work independently
Serves as a clinical resource to other areas within the clinical investigative team
Work with applicable business partners to obtain additional information relevant to the clinical review