M&R Clinical Investigator

UnitedHealth Group; United States; Remote; USD 50,000 - 89,000; Full time

Job summary

UnitedHealth Group is seeking a Senior M&R Clinical Investigator to determine the accuracy of provider-submitted claims by comparing them with medical records. The role requires navigating multiple systems, exercising judgment on complex payment decisions, and ensuring compliance with state and government guidelines.

The position supports telecommuting from anywhere in the U.S. and involves quality audits, data interpretation, and collaboration with medical directors to ensure proper coding and

Qualifications

• High School Diploma or GED required.
• AHIMA/AAPC certification or active nursing license with medical record auditing experience.
• 2+ years coding experience (CPT/HCPCS/ICD-10/CM/PCS).
• 1+ year in a metric-driven team environment.
• Advanced medical record review experience.
• Knowledge of health insurance terms, regulatory guidelines.
• Proficiency with Microsoft and Adobe applications; basic CPT/HCPCS knowledge.

Responsibilities

• Performs quality audits of clinical review cases for CPT/HCPCS and modifiers.
• Determines accuracy of medical coding/billing and payment recommendations for pre-payment claims.
• Researches state/federal mandates, policies, and clinical information to support reviews.
• Determines appropriate level of service using E/M principles.
• Ensures adherence to compliance and contract policies.
• Identify aberrant billing patterns and potential fraud indicators.
• Manage daily case review assignments with quality and productivity targets.
• Provide clinical support to other investigative and analytical areas.
• Collaborate in team and department meetings; work independently when needed.
• Coordinate with business partners to obtain necessary information.

Skills

Coding knowledge

Medical record review

Team collaboration

Data analysis

Communication skills

Education

High School Diploma or GED

AHIMA/AAPC certification

Nurse license (RN/LPN)

Bachelor's degree or higher

Tools

COSMOS

Facets

CPW

NICE

Microsoft Office

Adobe Acrobat

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.

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.

Day to Day 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 independently
• 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:

• Bachelor degree (or higher)
• 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
• [Internal Posting Only] 1+ year experience of UHC platforms - COSMOS, Facets, CPW, NICE
• 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. 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 $24.00 to $43.00 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.

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.

#RPO, #GREEN