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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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

In this position, you will apply your expert knowledge of Clinical validation criteria/guidelines as well as knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the review of inpatient claim audits. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis pertaining to Clinical validation billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will review clinical diagnostic audit rationales, written by non-clinicians and confirm clinical agreement with the audit findings.

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

Primary Responsibilities:

• Confirm findings on completed MS-DRG and APR-DRG clinical validation reviews to verify the accuracy of DRG assignment and reimbursement as it pertains to clinical criteria with a focus on overpayment identification

• Utilize knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance

• Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate expert knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments

• Perform, and provide oversight for clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing

• Utilize solid command of anatomy and physiology from specialized training and experience with ICD-10- CM code assignment

• Write/edit clear, accurate and concise rationales in support of findings using ICD-10 CM Official Coding Guidelines, and AHA Coding Clinics

• Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly

• Demonstrate knowledge of and compliance with changes and updates to clinical guidelines, reimbursement trends, and client processes and requirements

• Maintain and manage daily case review assignments, with a high emphasis on quality

• Provide clinical support and expertise to the other investigative and analytical areas

• Work in a high-volume production environment that is matrix driven

What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays

• Medical Plan options along with participation in a Health Spending Account or a Health Saving account

• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage

• 401(k) Savings Plan, Employee Stock Purchase Plan

• Education Reimbursement

• Employee Discounts

• Employee Assistance Program

• Employee Referral Bonus Program

• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

• More information can be downloaded at: http://uhg.hr/uhgbenefits

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:

• Associate’s Degree (or higher)

• Unrestricted RN (Registered Nurse) license

• 3+ years of MS DRG/APR DRG coding experience in a hospital environment with knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies

• 2+ years of ICD-10-CM coding experience including but not limited to knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)

Preferred Qualifications:

• Experience with prior DRG concurrent and/or retrospective overpayment identification audits

• Experience with DRG encoder tools (ex. 3M)

• Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry

• Healthcare claims experience

• Managed care experience

• Knowledge of health insurance business, industry terminology, and regulatory guidelines

Soft Skills:

• Ability to use a Windows PC with the ability to utilize multiple applications at the same time

• Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail

• Ability to work independently in a remote environment and deliver exceptional results

• Excellent time management and work prioritization skills

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, Hawaii, Washington or Washington, D.C. Residents Only : The hourly range for California, Colorado, Nevada, Connecticut, New York, New Jersey, Rhode Island, Hawaii, Washington or Washington, D.C. residents is $33.75 to $66.25 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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: 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.

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

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