Remote M&R Coding Clinical Investigator

Optum; Plymouth (MN); On-site; USD 48,000 - 89,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Job summary

Optum is hiring a M&R Coding Clinical Investigator to audit CPT/HCPCS coding on pre-payment claims and determine billing accuracy in a remote working setup across the U.S. You will interpret complex clinical data, coordinate with Medical Directors, and ensure compliance with policy and government guidelines.

The role requires AHIMA/AAPC credentials or active nurse license, 2+ years coding experience, and solid experience with medical record reviews.

Qualifications

• High School Diploma/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 an AHIMA or AAPC Certified coder with 2+ years of CPT/HCPCS/ICD/Modifiers – 10/CM/PCS coding experience or Licensed nurse with medical record auditing and coding/billing experience.
• 2+ years of experience with health insurance business, industry terminology, and regulatory guidelines.
• 1+ years of working in a team atmosphere in a metric driven environment including; daily production standards and quality standards.
• Intermediate level of experience with medical record review.
• Intermediate level of computer skills with the ability to troubleshoot problems.
• Basic level of experience with Microsoft & Adobe applications (outlook, power point, word, excel, pdf).

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.

Skills

Strong communication skills

Interpreting data

Analytical mindset

Medical terminology knowledge

Independent work

Education

AHIMA or AAPC certified coder (CPC/CCS/CCS-P) or Nurse (RN/LPN) with active license

Tools

Microsoft Office Suite

Adobe Acrobat/Adobe tools

Job description

Optum is hiring a M&R Coding Clinical Investigator to audit CPT/HCPCS coding on pre-payment claims and determine billing accuracy in a remote working setup across the U.S. You will interpret complex clinical data, coordinate with Medical Directors, and ensure compliance with policy and government guidelines.

The role requires AHIMA/AAPC credentials or active nurse license, 2+ years coding experience, and solid experience with medical record reviews.