RN Clinical Reviewer, CPC Medical Coding Academy - San Juan, PR

UnitedHealth Group • San Juan, PR

13h • Onsite

About The Position

Positions in this function investigates Optum Waste and Error stopped claims by gathering information, researching state and federal guidelines, and following internal procedure to determine the viability of the claim for further review in a production environment.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Requirements

• Coding Certificate or Nursing Licensure, for example: Puerto Rico Registered Nurse, Certified Professional Coder (CPC) + CPC A, Certified Inpatient Coder (CIC), Certified Outpatient Auditor (COC), Certified Professional Medical Auditor (CPMA), Certified Coding Specialist (CCS)
• Demonstrated proficiency with computers, including Microsoft Suite of products
• Ability to observe an on-site work model
• Willing or able to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL
• Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)

Nice To Haves

• Experience working with medical claims platforms
• Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting
• Presentation or policy documentation experience
• Proven knowledge of CMS and AMA coding rules specific to CPT, HCPCS
• Proven knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations
• Proven knowledge of Medicaid/Medicare Reimbursement methodologies
• Proven working knowledge of the healthcare insurance/managed care industry
• Proven working knowledge of medical terminology and claim coding

Responsibilities

• Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported
• Maintain standards for productivity and accuracy. Standards are defined by the department
• Provide clear and concise clinical logic to the providers when necessary
• Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
• Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
• Investigate and pursue recoveries
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Use pertinent data and facts to identify and solve a range of problems within area of expertise
• Attend and provide feedback during monthly meetings with assigned internal customer department
• Provide continuous feedback on how to improve the department relationships with internal team members and departments
• Keep up required Coding Certificate and/or Nursing Licensure
• Complete compliance hours as required by the department

Benefits

• comprehensive benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed