Program Integrity Clinical Compliance Auditor

About the position Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. The Sr. Recovery Resolution Analyst will be responsible for performing compliance reviews of medical and administrative documentation to identify instances of healthcare fraud and/or wasteful and abusive conduct by health care providers who submit claims for payment. This position will utilize information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations in order to document relevant findings. The Sr. Recovery Resolution Analyst will conduct site visits and desk audits of provider claims, and medical and administrative records, to gather and analyze all necessary information to determine whether subject adhered to state and federal compliance policies, reimbursement policies, and contract compliance. The Sr. Recovery Resolution Analyst will present and discuss audit findings with client and input information into Optum audit workflow tools and the client’s case tracking system. Where applicable, the Auditor will support appeal and fraud investigation activities.

Responsibilities

• Review medical and administrative records for audit/compliance review
• Travel to provider sites up to 25%25/month to collect records and engage with providers
• Present and participate in discussions with the client regarding audit observations and findings
• Collaborate with a team of 2-5 auditors to complete reviews
• Enter audit findings data and notes in online/electronic platform using Excel-based templates
• Attend and participate in dispute reviews and administrative hearings

Requirements

• High School Diploma / GED OR equivalent work experience
• Must be 18 years of age OR older
• Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts
• Must have a Valid Driver’s license
• 2+ years of experience reviewing health care documentation in a clinical or administrative role
• Experience with MS Office Suite, specifically Word, PowerPoint, and Excel (including familiarity with basic formulas and data analysis)
• Ability to travel up to 25%25 of the time within the state of Massachusetts as business needs dictate
• Ability to work full-time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime
• Reside within Massachusetts.
• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.
• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Nice-to-haves

• Clinical or administrative experience in long term care, for example, nursing facility care delivery/administration and/or community-based LTC service programs like Home Health
• Experience in claim processing, healthcare provider information, and healthcare billing practices
• Experience working in a remote/telecommute workspace
• Working knowledge of medical terminology and claim coding with familiarity of CPT-4, HCPCs and ICD-10 code terminology
• Familiarity with Medicaid program and/or billing requirements

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

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