Note: The job is a remote job and is open to candidates in USA. Optum is a global organization that delivers care aided by technology to help millions of people live healthier lives. The M&R Coding Clinical Analyst is responsible for determining the accuracy of claims submitted by providers, analyzing medical records, and ensuring compliance with coding requirements and policies. This role also involves managing caseloads and providing clinical expertise in a production-driven environment.
Responsibilities
- Performs quality audits of clinical review cases of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environment
- Determines accuracy of medical coding/billing and payment recommendation for pre-payment claims
- This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
- Determines appropriate level of service utilizing Evaluation and Management coding principles
- Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
- Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review
- Maintains and manages daily case review assignments, with accountability to quality, utilization and productivity standards
- Provides clinical support and expertise to the other investigative and analytical areas
- Participates in team and department meetings
- Engages in a collaborative work environment when applicable but is also able to work independently
- Serves as a clinical resource to other areas within the clinical investigative team
- Work with applicable business partners to obtain additional information relevant to the clinical review
Skills
- High School Diploma or GED
- Certified Coder AHIMA or AAPC Certified coder (CPC, CCS, CCS-P) or Nurse (RN, LPN) with unrestricted and active license/certification with medical record auditing and coding/billing experience
- 2+ years of experience as a AHIMA or AAPC Certified coder with 2+ years of CPT/HCPCS/ICD/Modifiers - 10/CM/PCS coding experience or Licensed nurse with medical record auditing and coding/billing experience
- 2+ years of experience with health insurance business, industry terminology, and regulatory guidelines
- 1+ year of working in a team atmosphere in a metric driven environment including; daily production standards and quality standards
- Intermediate level of experience with medical record review
- Intermediate computer skills with the ability to troubleshoot problems
- Basic experience with Microsoft & Adobe applications (outlook, power point, word, excel, pdf)
- Bachelor degree
- Healthcare claims experience/processing experience
- Strong communication skills with the ability to interpret data
- Experience with Fraud Waste & Abuse or Payment Integrity
- Experience with subsequent or reconsideration reviews for FWAE
- Strong analytical mindset working with medical terminology or coding
- [Internal Posting Only] 1+ year experience of UHC platforms - COSMOS, Facets, CPW, NICE
Benefits
- A comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution (all benefits are subject to eligibility requirements)
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