Remote Clinical Investigator — Medical Claims & Coding Audit

University of Minnesota School of Nursing; Plymouth (MN); Remote; USD 33,000 - 59,000; Full time

Job summary

UnitedHealth Group is seeking a M&R Clinical Investigator to determine the accuracy of provider-submitted claims by comparing to medical records and applying coding and reimbursement policies. This role requires independent, data-driven decision making and strong documentation skills.

You will perform quality audits, collaborate with clinical staff, and ensure compliance with state and federal guidelines while maintaining productivity metrics in a telecommuting environment.

Qualifications

• AHIMA or AAPC coder certification or active nursing license with medical record auditing experience.
• 2+ years of CPT/HCPCS/ICD-10-CM/PCS coding experience or licensed nurse with auditing experience.
• 1+ year in a metric-driven, production environment.
• Advanced medical record review experience.
• Intermediate knowledge of health insurance terminology and regulatory guidelines.
• Proficient with Microsoft Office and Adobe applications.

Responsibilities

• Performs quality audits of clinical review cases of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting environment.
• Determines accuracy of medical coding/billing and payment recommendations for pre-payment claims.
• Consults with Medical Director/physician when needed and interprets state/federal mandates, benefit language, and policies.
• Determines appropriate level of service using Evaluation and Management coding principles.
• Ensures adherence to state/federal compliance, reimbursement, and contract policies.
• Identifies aberrant billing patterns and potential fraud, waste, or abuse.

Skills

Coder certification or nursing license

Medical record auditing experience

CPT/HCPCS/ICD-10 coding experience

Team collaboration in metric-driven环境

Education

High School Diploma or GED

Bachelor degree (or higher)

Tools

Microsoft Office

Adobe Acrobat

Job description

UnitedHealth Group is seeking a M&R Clinical Investigator to determine the accuracy of provider-submitted claims by comparing to medical records and applying coding and reimbursement policies. This role requires independent, data-driven decision making and strong documentation skills.

You will perform quality audits, collaborate with clinical staff, and ensure compliance with state and federal guidelines while maintaining productivity metrics in a telecommuting environment.