M&R Coding Clinical Analyst

M&R Coding Clinical Analyst at UnitedHealth Group

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Remote: You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. The M&R Coding Clinical Analyst is required to determine the accuracy of claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. They must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and UHC/Client by following state and government compliance guidelines, coding requirements and policies. They must confidently analyze and interpret data and medical records/documentation on a daily basis to understand historical claims activity, determine validity and demonstrate their ability to provide written communication to the provider. They are responsible to investigate, review and provide clinical and/or coding expertise in a review of pre-payment claims. They need to effectively manage their caseload and monthly metrics in a production driven environment and ensure they are meeting all compliance turnaround times mandated by the client. The Senior Recovery Resolution Analyst must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. They must have the ability to research and work independently on making decisions on complex cases. 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 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