Supervisor, Claims Review - Remote in MA

UnitedHealth Group•Boston, MA

14h•$72,800 - $130,000•Remote

About The Position

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Audit Team Lead will be responsible for playing a leadership role in performing compliance reviews of medical and administrative documentation to identify instances of healthcare fraud and/or wasteful and abusive conduct by health care providers who submit claims for payment. This position will utilize information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations to document relevant findings. The Audit Team Lead will lead site visits and desk audits of provider claims, and medical and administrative records, to gather and analyze all necessary information to determine whether subject adhered to state and federal compliance policies, reimbursement policies, and contract compliance. The Audit Team Lead will present and discuss audit findings with clients and input information into Optum audit workflow tools and the client’s case tracking system. Where applicable, the Audit Team Lead will support appeal and fraud investigation activities. Finally, the Audit Team Lead will supervise and support the work of other Auditors in all the responsibilities noted here. This position is 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 EST. It may be necessary, given the business need, to work occasional overtime. We offer 8 weeks of paid training. The hours during training will be 8:00 am to 5:00 pm EST, Monday - Friday. If you are located in Massachusetts, you will have the flexibility to work remotely as you take on some tough challenges.

Requirements

Active nurse licensure (RN or LPN) in MA
1+ years of experience reviewing health care documentation in a clinical or administrative role
1+ years of basic experience with Excel, including familiarity with basic formulas and data analysis
Ability to work full time (40 hours/week), Monday - Friday, with flexibility for occasional overtime or weekend needs
Located and able to travel up to 10%25 within the state of Massachusetts

Nice To Haves

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
Working knowledge of medical terminology and claim coding
Familiarity with Medicaid program and/or billing requirements
Familiarity with CPT-4, HCPCs and ICD-10 code terminology

Responsibilities

Supervise and support the work of other Auditors as detailed below
Review medical and administrative records for audit/compliance review
Travel to provider sites up to 10%25/month to collect records and engage with providers
Present and participate in discussions with clients 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