Remote Payment Integrity Clinical Review Specialist

Taleo; La Crosse (WI); Remote; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive programs

Equity stock purchase

401k contribution

Job summary

UnitedHealth Group is seeking a Payment Integrity Clinical Review Specialist to help protect federal programs from fraud, waste, and abuse. This remote role requires RN licensure and CPC, with several years of claims auditing and healthcare investigations experience.

You will collaborate with PI teams, review records, apply regulations, and support investigations with federal law enforcement. The position offers strong benefits and opportunities for professional growth.

Qualifications

• Active, unrestricted RN license in state of residence.
• Certified Professional Coder (CPC).
• 3+ years of experience in a position processing medical claim auditing, payment integrity, and investigating fraud, waste, and abuse.
• 2+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment.
• 2+ years of clinical medical/surgical experience.
• 1+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity.
• Proven to be a Critical thinker.

Responsibilities

• Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations.
• Conduct provider claim and clinical audits, preparing clinical review summaries with recommendations and proper citations and resources.
• Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse.
• Support investigation and clinical discussions with federal law enforcement.
• Apply industry, state, and federal regulations and guidelines.
• Assess findings to detect patterns of fraud, waste, and abuse.
• Make accurate claim decisions based on VA policies, payment rules, coding guidelines, and clinical judgment.

Skills

RN license

CPC

Fraud detection

Clinical audits

Regulatory knowledge

Education

Graduate Degree

Tools

Facets

PGBA

Job description

UnitedHealth Group is seeking a Payment Integrity Clinical Review Specialist to help protect federal programs from fraud, waste, and abuse. This remote role requires RN licensure and CPC, with several years of claims auditing and healthcare investigations experience.

You will collaborate with PI teams, review records, apply regulations, and support investigations with federal law enforcement. The position offers strong benefits and opportunities for professional growth.