Clinical Consultant Mid Level- Remote

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 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.

  

The Mid-Level Practitioner role in the Clinical & Coding Advisory Team (CCAT) is a rare opportunity to work directly within Optum Payer Operations.  As a member of CCAT, you will play a vital role in helping stop fraud, waste, abuse, and error and help healthcare work better every day. 

  
The purpose of this job is to help people live their lives to the fullest by providing clinical leadership and expertise for the clinical investigation teams, including involvement in clinical reviews, provider education, high level appeals, development of clinical resources, and operations improvements. 

  

You’ll enjoy the flexibility to work remotely* from anywhere within the U.S. as you take on some tough challenges.

  

Primary Responsibilities:

• Provide expert clinical and strategic leadership for operational teams 
• Assist with high level clinical reviews (e.g. appeals, peer-to-peer, arbitration, etc.) 
• Collaborate with clinical operations teams on complex or difficult cases 
• Apply clinical knowledge in the interpretation of medical policy, clinical resources, and benefit document language in the review of professional and facility pre-pay and post-pay clinical reviews 
• Collaborate with and educate network and non-network providers on cases and clinical coding situations in pursuit of accurate billing practices 
• Actively participate in regular meetings and projects focused on clinical decision-making, clinical resources, analytics, savings, and staff training 
• Other duties and goals assigned by the Sr. Medical Director 

  

Critical Success Factors: 

• Solid understanding of Fraud, Waste, Abuse, and Error methodology 
• Solid problem-solving, negotiation and persuasion skills 
• Ability to effective lead, manage and deliver in a fast pace, ever changing environment 
• Ability to foster communications, robust collaboration, and solid partnerships among providers, clients, leaders, and clinical teams 

  

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:

• Current, active, and fully non-restricted licensed Nurse Practitioner or Physician Assistant 
• 3+ years of clinical practice experience  
• CPT/HCPCS/ICD-9/ICD-10 coding experience with a thorough knowledge of health insurance business, including knowledge of industry terminology and regulatory guidelines 
• Familiarity with current medical issues and practices 
• Proven excellent verbal and written communications skills  
• Proven solid team player and team building skills 
• Proven solid negotiation and conflict management skills 

  

Preferred Qualifications:

• Coding Certification thru AHIMA (CCS, CDIS, RHIA, RHIT) or AAPC (CIC) 
• 3+ years in facility (DRG and Clinical Validation Audit) reviews 
• 2+ years of experience in leading clinical operations within a health plan/or managed care environment to include client facing experience  
• Experience with Encoder and Grouper Software (3M) 
• Knowledge of federal (e.g., CMS) and state laws and regulations 

 

 *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy