RN Clinical Reviewer (CPC Medical Coding Academy) - San Juan, PR

Optum; San Juan (PR); On-site; USD 60,000 - 76,000; Full time

Job summary

UnitedHealth Group in San Juan, Puerto Rico, is seeking a skilled Clinical Auditor to review professional and facility claims, compare with medical records, and determine claim viability for further processing. The role emphasizes data accuracy, compliance, and clear clinical reasoning for providers.

The position requires a Coding Certificate or Nursing Licensure, proficiency with Microsoft Office, and fluency in English and Spanish.

Qualifications

• Coding Certificate or Nursing Licensure is required.
• Proficiency with computers including the Microsoft Office suite.
• Professional proficiency in both English and Spanish (an English proficiency assessment may be required).

Responsibilities

• Perform clinical review of professional or facility claims against medical records.
• Maintain productivity and accuracy standards as defined by the department.
• Provide clear clinical logic to providers and ensure data integrity and compliance.

Skills

Coding Certificate

Nursing Licensure

MS Office

English/Spanish

On-site work model

Tools

Microsoft Office

Job description

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Positions in this function investigates Optum Waste and Error stopped claims by gathering information, researching state and federal guidelines, and following internal procedure to determine the viability of the claim for further review in a production environment.

Primary Responsibilities

• Clinical Case Reviews -75%
  • Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported
  • Maintain standards for productivity and accuracy. Standards are defined by the department
  • Provide clear and concise clinical logic to the providers when necessary
  • Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
  • Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
  • Investigate and pursue recoveries
  • Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
  • Use pertinent data and facts to identify and solve a range of problems within area of expertise
  • Other internal customer correspondence and team needs - 15%
  • Attend and provide feedback during monthly meetings with assigned internal customer department
  • Provide continuous feedback on how to improve the department relationships with internal team members and departments
• Continuing education - 10%
  • Keep up required Coding Certificate and/or Nursing Licensure
  • Complete compliance hours as required by the department
  • ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION***

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• Coding Certificate or Nursing Licensure, for example:
  • Puerto Rico Registered Nurse
  • Certified Professional Coder (CPC) + CPC A
  • Certified Inpatient Coder (CIC)
  • Certified Outpatient Auditor (COC)
  • Certified Professional Medical Auditor (CPMA)
  • Certified Coding Specialist (CCS)
• Demonstrated proficiency with computers, including Microsoft Suite of products
• Ability to observe an on-site work model
• Willing or able to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL
• Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)

Preferred Qualifications

• Experience working with medical claims platforms
• Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting
• Presentation or policy documentation experience
• Proven knowledge of CMS and AMA coding rules specific to CPT, HCPCS
• Proven knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations
• Proven knowledge of Medicaid/Medicare Reimbursement methodologies
• Proven working knowledge of the healthcare insurance/managed care industry
• Proven working knowledge of medical terminology and claim coding

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.