RN Clinical Reviewer, CPC Medical Coding Academy - San Juan, PR at UnitedHealth Group Canada

, Puerto Rico, United States -

Full Time

Start Date

Immediate

Expiry Date

14 Feb, 26

Salary

0.0

Posted On

16 Nov, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Registered Nurse, Coding Certificate, Medical Coding, Clinical Review, Data Integrity, Compliance Policies, Claims Investigation, Microsoft Suite, Bilingual, Healthcare Insurance, Medical Terminology, CPT Coding, HCPCS Coding, Medicaid Reimbursement, Medicare Reimbursement, Evaluation and Management Services

Industry

Hospitals and Health Care

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. 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. Primary Responsibilities: Clinical Case Reviews -75%25 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 Other internal customer correspondence and team needs - 15%25 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 Continuing education - 10%25 Keep up required Coding Certificate and/or Nursing Licensure Complete compliance hours as required by the department ***ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION*** 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: Registered Nurse (RN), 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) Experience in a hospital/inpatient setting, surgical or clinic Demonstrated proficiency with computers, including Microsoft Suite of products 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) Preferred Qualifications: 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 Knowledge of CMS and AMA coding rules specific to CPT, HCPCS Knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations Knowledge of Medicaid/Medicare Reimbursement methodologies Working knowledge of the healthcare insurance/managed care industry Working knowledge of medical terminology and claim coding 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.

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Responsibilities

The RN Clinical Reviewer performs clinical reviews of claims against medical records to determine their viability. They also investigate claims, ensure compliance with policies, and provide feedback to improve departmental relationships.