For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)

Join Optum Serve as a Senior Payment Integrity Clinical Review Specialist. Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. We help our clients and the communities they serve prevent, prepare for, respond to, and recover from emergencies and long-term public health challenges. Optum Serve’s Technology Services business unit focuses on health information technology and how to further federal customers’ missions by continually looking for ways to increase efficiency and thereby, lower costs.

With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Senior Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Join Optum Serve’s Technology Services team to help protect our nation’s most critical federal programs.

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

Primary Responsibilities:

• Collaborate with a team that is triaging, investigating and medical reviewing instances of health care fraud and/or abusive conduct
• Conduct provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation including preparation of written and verbal case summaries with recommendations for further actions
• Perform clinical review of medical record and claims data for PI cases
• Perform clinical review of PI cases in which an allegation of Fraud Waste or Abuse has been identified in accordance with all State and Federal mandated regulations/guidelines
• Assess investigative and medical review findings, and/or other claims data to determine patterns and detect potential fraud, waste and abuse
• Perform accurate claim decision coverage determinations based on applicable VA coverage policies and payment rules, coding guidelines, Medicare and Medicaid National and Local Coverage Determinations, utilization/practice guidelines, and clinical review judgment
  

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:

• Active, unrestricted RN license in state of residence
• 5+ years of experience in a position processing medical claim, auditing, payment integrity, and/or investigating fraud (health care fraud investigations experience preferred)
• 3+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment
• 3+ years of clinical medical/surgical experience
• 2+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity
  

Preferred Qualifications:

• Graduate Degree
• Certified Coding Specialist
• Certified Fraud Examiner
• Experience training and coaching other team members
• An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance)
• Experience with Facets, iDRS, CSP, Macess, or other claims processing systems
  

Careers at OptumCare . We're on a mission to change the face of health care. As the largest health and wellness business in the US, we help 58 million people navigate the health care system, finance their health care needs and achieve their health and well-being goals. Fortunately, we have a team of the best and brightest minds on the planet to make it happen. Together we're creating the most innovative ideas and comprehensive strategies to help heal the health care system and create a brighter future for us all. Join us and learn why there is no better place to do your life's best work.(sm)

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

California, Colorado, Connecticut, Nevada, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New York, Rhode Island or Washington residents is $85,000 to $167,300. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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

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.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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