Title: DRG/Clinical Validation Auditor RN Location: US Work Type: Remote, Full Time Job ID: 2329289 Job Description: 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. In this position as a Clinical DRG RN auditor, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification - Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance - Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments - Perform clinical coding review to ensure accuracy of medical coding and utilize clinical expertise and judgment to determine correct coding and billing - Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment - Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics - Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly - Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements - Maintain and manage daily case review assignments, with a high emphasis on quality - Provide clinical support and expertise in the other investigative and analytical areas - Work in a high-volume production environment that is matrix driven What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include: - Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays - Medical Plan options along with participation in a Health Spending Account or a Health Saving account - Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage - 401(k) Savings Plan, Employee Stock Purchase Plan - Education Reimbursement - Employee Discounts - Employee Assistance Program - Employee Referral Bonus Program - Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.) You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - Associate's Degree (or higher) - Unrestricted RN (Registered Nurse) license - CCS/CIC or willing to obtain certification within 6 months of hire - 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies - 2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM) - 2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers Preferred Qualifications: - Experience with prior DRG concurrent and/or retrospective overpayment identification audits - Experience working with Utilization Management - Experience with readmission reviews of claims - Experience with DRG encoder tools (ex. 3M) - Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry - Healthcare claims experience - Managed care experience - Knowledge of health insurance business, industry terminology, and regulatory guidelines Soft Skills: - Ability to use a Windows PC with the ability to utilize multiple applications at the same time - Ability to work independently in a remote environment and deliver exceptional results - Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail - Excellent time management and work prioritization skills Physical Requirements and Work Environment: - Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer - Have a secluded office area in which to perform job duties during the work day - Have reliable high-speed internet access and a work environment free from distractions - All Telecommuters 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 hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. 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.

Title: Senior Credentialing Representative - Quality Auditor Location: United States Job Description: Requisition number: 2349644 Job category: Network Management Overtime status: Non-exempt Travel: No 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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. The Senior Credentialing Representative is responsible for ensuring that credentialing information and data meets internal and external quality standards and requirements. Internal audits are performed against established standards for all credentialing and recredentialing functions within the Credentialing Center of Excellence (CCoE). The SCRA will document findings, identify trends, and recommend opportunities for improvement. Location: Remote, Nationwide Schedule: Monday to Friday, 8 AM- 5 PM You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Credentialing File Review/Audit: - Performs daily audits of credentialing and recredentialing files utilizing standardized audit template - Ensures audits are performed within established timeframes - Communicates identified errors to credentialing representatives and specialists utilizing established processes Process improvement: - Participates in audit result review and track and trend of results - Participates in root cause analysis - Reviews repeat errors for potential training opportunities - Provides explanations and interpretations within area of expertise - Identifies potential process improvement needs to workflows and procedures - Communicates potential and identified trends to leadership Delegation Oversight: - Collect and review credentialing files and materials for submission to delegating health plans at time of initial and annual delegation oversight audits - Collect and review submitted sub-delegated files and materials at time of pre-assessment and annual delegation oversight audits - Other department duties as assigned Knowledge, Skills, and Abilities: - Demonstrated understanding credentialing information processes - Established knowledge of credentialing requirements to include NCQA, CMS, and state-specific regulations - Attention to detail, ability to identify inconsistencies and missing information - Consistently delivers excellent quality of credentialing files processed - Analytical and critical thinking skills - Ability to research and evaluate credentialing criteria when questions or discrepancies are presented - Strong communication skills, ability to communicate clearly and professionally in written or oral formats - Ability to identify problems, analyze data and recommend solutions - Ability to maintain confidential information in accordance with Company policies, state, and federal regulations - Ability to manage detail and work with accuracy - Ability to acquire knowledge of technical resources within the organization - Ability to work independently - Ability to establish and maintain cooperative working relationships with individuals at all levels including teammates from other teams - Ability to work with frequent interruptions - Ability to prioritize work and skill in working effectively under deadlines and changing priorities - Demonstrated knowledge of Microsoft Office applications such as Word, Excel, and Outlook - Intermediate level skills working in Microsoft Excel - Consistently delivers excellent quality of work You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - High School Diploma/GED (or higher) - 2+ years of experience in credentialing - 1+ years of proven consistent quality audit scores passing or exceeding requirements - 1+ years of experience using credentialing software or software managing provider information Preferred Qualifications: - Experience using MD-Staff credentialing software *All Telecommuters 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 hourly pay for this role will range from $20.38 to $36.44 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. 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.

Role Description Performs quality reviews and audits to ensure compliance with DRG validation, ICD-10/PCS, and CPT coding guidelines. Coordinates with department leadership to ensure standards are met in accordance with department and organization policy. Contributes to improving the processes and infrastructure of the department. Demonstrates proficiency in facilitation and interpersonal communication, organizational skills, prioritization of tasks, professionalism, and educating and training as required. Uses in-depth understanding of the CQR quality workplan to promote compliance and awareness of the plan. Acts as a subject matter expert (SME) in national coding guidelines for hospital inpatient, outpatient, and/or Professional fee coding and ensures compliance with those guidelines along with all company coding policies. Uses performance improvement analyses to improve the accuracy, integrity, and quality of patient data, ensure minimal variation in coding practices, and improve the quality of physician documentation within the body of the medical record to support code assignments which results in appropriate reimbursement and data integrity. Qualifications - High School Education/GED or equivalent: Required - Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred - Five years' acute care inpatient, outpatient coding experience, and/or professional fee coding: Required - Three years' coding auditing/monitoring experience: Preferred - Certified Coding Specialist credential (CCS) through AHIMA or AAPC; credential type specific to auditing being performed: Required Requirements - Performs regularly scheduled quality reviews and audits per departmental policies and procedures (routine, pre-bill, policy driven, targeted, and post-bill) for hospital inpatient, outpatient, and/or professional fee coding. - Facilitates the coder audit appeal process, providing rationale and education to the coding team as required. - Performs ad hoc quality reviews, such as targeted DRG reviews, and special projects as assigned by management. - Prepares detailed audit reports outlining findings, recommendations, rationale, and corrective actions needed. - Facilitates the coder appeal process. - Assists team members with coding questions and provides resolution guidance. - Assists in ensuring coding staff adherence with coding guidelines and policy, both internal and vendor teams. - Demonstrates and applies expert level knowledge of medical coding practices and concepts. - Communicates appropriately with manager and all stakeholders as required. - Identifies and communicates educational opportunities to manager. - Maintains working knowledge of workflows, systems, and tools used in the department. - Reviews all official data quality standards, coding guidelines, company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current. - Maintains up-to-date knowledge of medical terminology, coding guidelines, quality standards, regulatory changes, etc. that affect the audit process. - Assists in creation and maintenance of a positive working environment, including effective communication and setting an appropriate professional example. - Performs other job-related duties as assigned. Company Description Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.

Role Description Performs assessments of the design and effectiveness of operational, compliance and financial internal controls independently. Performs project planning, risk assessment and time accounting efforts. Assesses compliance with policies and procedures and provides recommendations for improved controls. Implements large/multiple projects simultaneously. Functions as lead on certain projects and may lead teams. Coaches development of Auditors. Key Responsibilities - Leads project planning function, including risk assessment development, audit program development and time accounting. - Leads entrance and exit conferences keeping internal client apprised of project status, audit observations and potential recommendations. - Assesses policies, procedures, and internal controls for adequacy of design and effectiveness and analyzes financial transactions and operations. - Makes recommendations to improve controls. May participate in institutional task forces and other special committees related to the achievement of goals and objectives. - Promotes awareness of internal controls and provides a mechanism to heighten customer awareness of the internal audit function and assurance and advisory services performed. - The responsibilities listed are a general overview of the position and additional duties may be assigned. Technical Capabilities - Audit Leading Practices (Advanced): The sets of refined policies, procedures, processes, techniques, tools and methodologies that have been optimized for efficiency and effectiveness, and adopted within the organization. - Audit Planning (Advanced): Ability to anticipate resource needs and then arrange, prioritize and shape activities to meet objectives. - Operational Auditing (Advanced): Ensuring compliance with established policy and procedures and recommending any necessary changes. - Control Testing (Advanced): The activities performed by auditors in gathering evidence as to the effectiveness of operations of control procedures. - Variance Analysis (Advanced): Ability to analyze the factors that have caused the difference between the pre-determined standards and the actual results. Core Accountabilities - Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams. - Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solutions. - Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas. - Team Interaction: Acts as a "go-to" resource for colleagues with less experience; may lead small project teams. Core Capabilities - Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. - Delivering Excellent Services: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. - Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. - Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. - Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements. Position Qualifications - Relevant Work Experience: 5 years - Education: Bachelor's Benefits This role offers the opportunity to make a meaningful impact within Vanderbilt Health, supported by a comprehensive benefits package which may include health, disability, retirement and/or wellness offerings to enhance your well-being and professional growth. Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity. EOE/Vets/Disabled.