M&R Clinical Investigator

UnitedHealth Group; Plymouth (MN); Remote; USD 33,000 - 59,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Job summary

UnitedHealth Group is seeking a M&R Clinical Investigator to determine the accuracy of provider-submitted claims by comparing to medical records. The role requires strong coding knowledge, independent decision‑making, and compliance with government guidelines. The position offers telecommuting from anywhere in the U.S.

and a production-driven environment. The successful candidate will audit CPT/HCPCS coding, review medical necessity, and collaborate with Medical Directors and other teams to

Qualifications

• High School Diploma or GED (required)
• AHIMA or AAPC certification (CPC, CCS, CCS-P) or Nurse with active license and coding experience
• 2+ years as a certified coder with CPT/HCPCS/ICD‑10/CM/PCS experience or licensed nurse with medical record auditing experience
• 1+ year of team experience in a metric-driven environment
• Advanced medical record review experience
• Intermediate to advanced health insurance knowledge and regulatory guidelines
• Basic to intermediate experience with Microsoft & Adobe applications (Outlook, PowerPoint, Word, Excel, PDF)
• Beginner knowledge of CPT/HCPCS/Modifiers (Medical necessity and DRG review not required)

Responsibilities

• Perform quality audits of clinical review cases for CPT, HCPCS, and modifiers on claims in a telecommuting environment
• Determine accuracy of medical coding and payment recommendations for pre‑payment claims
• Consult with Medical Director/physician and interpret mandates, policy language and reimbursement rules
• Determine appropriate level of service using E/M coding principles
• Ensure compliance with state/federal policies, reimbursement rules and contracts
• Identify aberrant billing patterns and potential fraud or abuse and flag providers for review
• Manage daily case assignments with quality, utilization and productivity targets
• Provide clinical support to investigative and analytical teams
• Participate in team and department meetings
• Collaborate with business partners and research additional information as needed

Skills

Strong communication skills

Analytical mindset

Healthcare terminology

Education

AHIMA or AAPC certification (CPC/CCS/CCS-P)

Nurse license (RN/LPN)

Tools

Microsoft Office

Adobe Acrobat

Job description

Improve the lives of others while Caring. Connecting. Growing together.

Job Description - M&R Clinical Investigator (2397679)

M&R Clinical Investigator - 2397679

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 M&R Clinical Investigator is required to determine the accuracy of claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. They must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and UHC/Client by following state and government compliance guidelines, coding requirements and policies. They must confidently analyze and interpret data and medical records/documentation on a daily basis to understand historical claims activity, determine validity and demonstrate their ability to provide written communication to the provider. They are responsible to investigate, review and provide clinical and/or coding expertise in a review of pre-payment claims. They need to effectively manage their caseload and monthly metrics in a production driven environment and ensure they are meeting all compliance turnaround times mandated by the client. The Senior Recovery Resolution Analyst must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. They must have the ability to research and work independently on making decisions on complex cases.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

• Performs quality audits of clinical review cases of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environment
• Determines accuracy of medical coding/billing and payment recommendation for pre-payment claims
• This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
• Determines appropriate level of service utilizing Evaluation and Management coding principles
• Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
• Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review
• Maintains and manages daily case review assignments, with accountability to quality, utilization and productivity standards
• Provides clinical support and expertise to the other investigative and analytical areas
• Participates in team and department meetings
• Engages in a collaborative work environment when applicable but is also able to work independent
• Serves as a clinical resource to other areas within the clinical investigative team
• Work with applicable business partners to obtain additional information relevant to the clinical review

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

• High School Diploma or GED
• Certified Coder AHIMA or AAPC Certified coder (CPC, CCS, CCS-P ) or Nurse (RN, LPN) with unrestricted and active license/certification with medical record auditing and coding/billing experience
• 2+ years of experience as a AHIMA or AAPC Certified coder with 2+ years of CPT/HCPCS/ICD – 10/CM/PCS coding experience or Licensed nurse with medical record auditing and coding/billing experience
• 1+ year of working in a team atmosphere in a metric driven environment including; daily production standards and quality standards
• Advanced medical record review experience
• Intermediate to advanced knowledge of health insurance business, industry terminology, and regulatory guidelines
• Basic to intermediate experience with Microsoft & Adobe applications (outlook, power point, word, excel, pdf)
• Beginner knowledge including CPT/HCPCS/Modifiers (Medical necessity and DRG review experience is not applicable to this position)

Preferred Qualifications

• Healthcare claims experience/processing experience
• Strong communication skills with the ability to interpret data
• Experience with Fraud Waste & Abuse or Payment Integrity
• Experience with subsequent or reconsideration reviews for FWAE
• Strong analytical mindset working with medical terminology or coding
• Must be proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexity
• Must have strong computer skills with the ability to troubleshoot problems

*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. The hourly pay for this role will range from $24.00 to $43.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

In addition to your salary, we offer benefits such as:

• a comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 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.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

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.

UnitedHealth Group is committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need special assistance or accommodation for any part of the application process, please call 1-866-566-8715 to be connected to Recruitment Services. Recruitment Services hours of operation are 7 a.m. to 7 p.m. CT, Monday through Friday.

UnitedHealth Group is a registered service mark of UnitedHealth Group, Inc. The UnitedHealth Group name with the dimensional logo, as well as the dimensional logo alone, are both service marks for the UnitedHealth Group, Inc.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug‑free workplace. Candidates are required to pass a drug test before beginning employment.