Senior Clinical Investigator

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.

Prepay Coding Investigation Consultant is responsible for investigating and resolving instances of healthcare fraud and abuse of medical providers. Coding Investigation Consultant uses information from a tip, member benefits, and medical records to document relevant findings. This position will achieve applicable targets and metrics as determined.  As a senior level staff person, this individual will provide mentoring, explanations, and feedback to others on difficult issues.  This position assists with projects both internal and external to the team. The Coding Investigation Consultant provides coding guidance to investigators on CPT codes relevant to an investigation. This position works with minimal guidance and seeks input on the most complex of tasks. Works with internal and external stakeholders to facilitate client requests and maintains compliance with regulatory requirements.

Primary Responsibilities:

• Reviews prepay claims with corresponding medical records to determine payment accuracy
• Reviews applicable policies, CPT guidelines and contracts as they pertain to clinical review
• Participates in regulatory meetings with client
• Participates in meetings with providers, advocates and legal to assist with provider abrasion
• Performs additional projects as needed by the business or Client; analyzes data; meets with internal and external stakeholders as necessary for resolution
• Continuous monitoring of claim inventory in order to adhere to performance guarantees
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• Graduate of 4-year course of Allied Medical Health
• Certified Professional Coder – CPC
• 1+ years clinical/coding experience (surgical, hospital, clinic settings)
• CPT & ICD coding experience or must pass AAPC CPC Certification provided by Optum
• Thorough knowledge of PC based software
• Proven critical thinking, problem solving, and analytical skills

Preferred Qualifications:

• Graduates of Allied Medical Health (Registered Nurse/Physiotherapist/Radiologic Technologist/ Pharmacist)
• Experience with health insurance billing/coding
• Proven ability to prioritize and manage multiple tasks
• Proven ability to work in a team setting
• Proven excellent oral and written communication skills and presentation skills

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.