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UnitedHealth Group is a healthcare and well-being company that’s dedicated to improving the health outcomes of millions around the world. We are comprised of
Senior Clinical Consultant Audit/Recovery Payment Integrity
Location
United States
Posted
2 days ago
Salary
$72.8K - $130K / year
Seniority
Senior
No structured requirement data.
Job Description
Senior Clinical Consultant Audit/Recovery Payment Integrity
UnitedHealth Group
Role Description 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. - Conduct extensive audits on a project basis and generate response letters for review by medical director(s). - Monitor action plans as a result of the audit and track/document the whole process. - 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. - Work with Payment Integrity Analytics to determine audit sample and if a statistical extrapolation is possible. - Conduct audits of provider records and claims submissions to ensure appropriateness of billing practices. - Identify and document fraudulent or erroneous activity during an audit. - Determine actual overpayment that may have occurred and generate written notice to providers on audit findings. - 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. - Act as a consultant to claims coding professionals when additional information or documentation is needed. - Take ownership of the total work process and provide constructive information to minimize problems. - Detect and identify aberrant behavior for providers and facilities. - Identify updated clinical analytics opportunities and participate in projects as necessary. - Maintain and manage case review assignments. - Ensure issues are identified, tracked, reported, and resolved. - Develop relevant training programs, policies, and procedures for claims and benefit staff. - Review and edit requirements, specifications, business processes, and recommendations related to proposed solutions. - 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. - Modify the system specifications as changes in regulation occur. - Perform other duties as assigned. 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. - 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 a 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. - 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. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase. - 401k contribution (all benefits are subject to eligibility requirements). 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.
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