Payment Integrity Clinical Review Specialist - Fraud Waste and Abuse - Optum Serve - Remote

UnitedHealth Group•La Crosse, WI

9d•$72,800 - $130,000•Remote

About The Position

Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. We help our clients and the communities they serve to prevent, prepare for, respond to, and recover from emergencies and long-term public health challenges. Optum Serve’s Technology Services business unit focuses on health information technology and how to further federal customers’ missions by continually looking for ways to increase efficiency and thereby, lower costs. With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Join Optum Serve’s Technology Services team to help protect our nation’s most critical federal programs. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Requirements

Active, unrestricted RN license in state of residence
Certified Professional Coder (CPC)
3+ years of experience in a position processing medical claim auditing, payment integrity, and investigating fraud, waste, and abuse
2+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment
2+ years of clinical medical/surgical experience
1+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity
Proven to be a Critical thinker

Nice To Haves

Graduate Degree
Certified Coding Specialist
Certified Fraud Examiner
Experience training and coaching other team members
Experience with Facets, PGBA, or other claims processing systems
An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance)

Responsibilities

Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations
Conduct provider claim and clinical audits, preparing clinical review summaries with recommendations and proper citations and resources
Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse
Support investigation and clinical discussions with federal law enforcement
Apply industry, state, and federal regulations and guidelines
Assess findings to detect patterns of fraud, waste, and abuse
Make accurate claim decisions based on VA policies, payment rules, coding guidelines, and clinical judgment