Remote Payment Integrity Clinical Review Specialist

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

Benefits offered by this job

Remote work within the U.S.

Office requirement in Minneapolis/DC (

Job summary

Optum serves as a Payment Integrity Clinical Review Specialist, focusing on identifying fraud, waste, and abuse in healthcare claims and audits. Remote work is available nationwide with in-office requirement only for certain regions, ensuring compliance with federal guidelines.

The role emphasizes collaboration with PI teams, clinical record reviews, and interface with federal law enforcement, requiring RN licensure and CPC certification along with relevant experience.

Qualifications

• Active, unrestricted RN license in state of residence.
• Certified Professional Coder (CPC).
• 3+ years of experience in medical claim auditing, payment integrity, and investigating fraud, waste, and abuse.
• 2+ years in government, legal, investigations, health care managed care, or health insurance environments.
• 2+ years of clinical medical/surgical experience.
• 1+ years researching billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity.
• Proven to be a critical thinker.

Responsibilities

• Collaborate with the Payment Integrity team on healthcare fraud, waste, and abuse investigations.
• Conduct provider claim and clinical audits, prepare clinical review summaries with recommendations and proper citations.
• 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

Critical thinking

Education

RN license (state of residence)

Certified Professional Coder (CPC)

Tools

Facets

PGBA

Job description

Optum serves as a Payment Integrity Clinical Review Specialist, focusing on identifying fraud, waste, and abuse in healthcare claims and audits. Remote work is available nationwide with in-office requirement only for certain regions, ensuring compliance with federal guidelines.

The role emphasizes collaboration with PI teams, clinical record reviews, and interface with federal law enforcement, requiring RN licensure and CPC certification along with relevant experience.