1+ months

Payment Integrity Consultant US Remote - 917316

San Antonio, TX 78205 Work Remotely
  • Job Code
    917316

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your lifes best work.(sm)

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The Consultant, Claims Adjudication & Payment Integrity position is responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical documentation, and published CMS, Coding and other industry criteria. Conducts audits of medical coding to increase coding accuracy and identify potential FWAE. Completes comprehensive examinations of medical records and supporting documents. Provides support related to coding and billing issues to maintain compliance with policies, procedures, laws, and government regulations

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Youll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

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Primary Responsibilities:

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  • Takes ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
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  • FWAE detection and identification of aberrant behavior for providers and facilities
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  • Investigate, review and provide clinical and/or coding expertise in review of post-service, pre-payment or post-payment claims; which requires interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies and coding requirements. Consideration of relevant clinical information on claims with overt billing patterns
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  • Make pay/deny recommendation decisions based on findings; this could include Medical Director/physician consultations and working independently while making decisions
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  • Identify updated clinical analytics opportunities and participate in projects as necessary
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  • Maintain and manage case review assignments
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  • Ensure issues are identified, tracked, reported and resolved
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  • Escalate issues as needed for support and/or guidance
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  • Keep abreast of current Medicare guidelines and regulations by reviewing updates, bulletins and changes to CMS manuals
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  • Performs all other related duties as assigned
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Youll 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.

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Required Qualifications:

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  • Associates degree in Healthcare Administration, Business or a related field or HS Diploma/GED with 2 years of relevant experience above required years of experience may be considered in lieu of Associates Degree
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  • Four or more years of experience in medical claims professional procedure coding and processing.
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  • Coding certification through AAPC or AHIMA. Candidates without certification will not be considered.
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  • Strong knowledge of Medicare/CMS claims regulations and policies.
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  • Experience in reading, interpreting and applying Medicare and CMS Claims and Policies (NCD/LCD/NCCI)
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  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
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Preferred Qualifications:

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  • 7+ years in a Medical Insurance environment
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  • Strong analytical and research skills
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  • Experience working in Payment Integrity, Fraud Waste and Abuse or Special Investigations
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  • Experience in communicating complicated concepts and information to a wide range of audiences
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  • Experience working with process improvement teams and streamlining processes as required and improving departmental efficiencies
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  • Experience with Encoder Pro
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  • Excellent written and verbal communication skills
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Careers with WellMed.Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 380,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to doyour life's best work.(sm)

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"*All Telecommuters will be required to adhere to UnitedHealth Groups Telecommuter Policy.

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Colorado Residents Only: The hourly range for Colorado residents is $25.63 to $45.72. 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, youll find a far-reaching choice of benefits and incentives

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"Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

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

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Job Keywords: CPC, Coding, American Academy of Professional Coders, AAPC, CPC-A, CRC, Clinical Documentation Improvement, Nurse Auditor, Risk Adjustment, Data Rap, ICD, CPT, Analysis, Clinical Education, CMS-HCC Model, Medical Records Reviewer

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Categories

Posted: 2021-03-02 Expires: 2021-04-30

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Payment Integrity Consultant US Remote - 917316

UnitedHealth Group
San Antonio, TX 78205

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