SR Clinical Consultant Audit/Recovery Payment Integrity
SR Clinical Consultant Audit/Recovery Payment Integrity
Description
Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Explore rewarding opportunities for physicians, clinical staff and non-patient-facing roles. Join us and discover the meaning behind Caring. Connecting. Growing together.
The Sr. Clinical Consultant - Payment Integrity position is responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical documentation, and published CMS, Coding and other industry criteria. This position will provide direction and guidance to Medical Coding Analysts, as well as cross-functional team members within Payment Integrity and Claims. Responsible for communication with medical professionals and written education material to support improved documentation and correct coding in future.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
Investigate, review, and provide clinical and / or coding expertise in review of post - service, pre- payment or post payment claims, which requires interpretation of state and federal mandates, billing practices / patterns, applicable benefit language, medical and reimbursement policies, medical necessity, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make pay / deny or payment recommendation decisions based on findings; this could include Medical Director / physician consultations and working independently while making their decisions
Conduct extensive audits on a project basis: generate response letter for review by medical director(s). Monitor action plan as a result of the audit - responsible for tracking and documenting the whole process
Positions in this function perform comprehensive research and identify billing abnormalities, questionable billing practices, and/or irregularities
Investigate, research, and analyze claims data applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive billing activity
Work with Payment Integrity Analytics to determine audit sample and if a statistical extrapolation is possible what is that audit size
Conduct audits of provider records, and claims submissions to ensure appropriateness of billing practices and application of medical policy
Identify and document fraudulent or erroneous activity during an audit
Determine actual overpayment that may have occurred. Generates written notice to providers on audit findings and works with claims and legal to obtain overpayment
Participate in case review and medical determination conference/consults
Conduct reviews for medical necessity and determination of correct coding
Facilitate improvement in overall quality, completeness, and accuracy of medical record documentation
Coordinate education related to compliance, coding, and clinical documentation for payment integrity issues within the healthcare organization
Act as a consultant to claims coding professionals when additional information or documentation is needed to assign coded data
Take ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
FWAE detection and identification of aberrant behavior for providers and facilities
Identify updated clinical analytics opportunities and participate in projects as necessary by client / other departments
Maintain and manage case review assignments
Ensure issues are identified, tracked, reported and resolved
Develop relevant training programs, policies and procedures, and resources that enable the claims and benefit load staff to process and perform job duties with accurate and timely information
Review and edit requirements, specifications, business processes and recommendations related to proposed solutions and write business rules to support benefit and claims functions
Work directly with management teams on quality results, trending analysis and needed process improvement
Escalate issues to project team and management for support and / or guidance
Keep abreast of current Medicare guidelines and Regulations and compliance standards by reviewing all updates / bulletins and changes
Modify the system specifications as changes in regulation occur
Performs other duties as assigned
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.
Required Qualifications:
Bachelor's Degree in Nursing required (Associate's Degree or Nursing Diploma from accredited nursing school with 2 or more years of additional experience may be substituted in lieu of a bachelor's degree) and current RN license in good standing
4+ years of ICD-9, ICD10 coding experience and medical review of Medicare claims and medical documentation with medical chart review experience
4+ years associated business experience with Medicare policies and regulations
Solid knowledge of the Medicare policies, CMS NCDs, LCDs and Articles
Preferred Qualifications:
CPC certification from the American Academy of Professional Coders
5+ years in a Medicare Insurance environment
Experience working as medical review nurse and coder with strong analytical and research skills
Experience in working in a MAC or RAC with medical review and payment integrity functions
Experience working with process improvement teams and streamlining processes as required and improving departmental efficiencies
Experience with Encoder Pro
Proven excellent written and verbal communication skills
Proven ability to solve process problems crossing multiple functional areas and business units
Proven solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action
Proven good business acumen, especially as it relates to Medicare
MS Office Suite, moderate to advanced EXCEL and PowerPoint skills
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
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.
Optum, part of the UnitedHealth Group family of businesses, 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 h...