Remote Clinical Claims Investigator - Coding & Audit

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

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