Clinical Investigation Analyst - San Juan, Puerto Rico - 2041311
San Juan
hace 1 día

Primary Responsibilities :

  • 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, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make pay / deny or payment recommendation decisions based on findings;
  • this could include Medical Director / physician consultations and working independently while making their decisions

  • Identify overt billing trends, waste and error identification, and recommends providers to be flagged or filtered for review and works with analytics on recommendations to increase line of business savings by client
  • Identify updated clinical analytics opportunities and participates in projects necessary by client / other departments
  • Maintain and manage daily case review assignments, with a high emphasis on quality, with at least 98% accuracy and within client / CMS guidelines and provides clinical explanation both to the provider
  • Participate in provider / client / network meetings, which may include provider education through written communication and participates in additional projects as needed
  • Participate in training of new staff and serves as a clinical resource to other areas within the clinical investigative team and provides guidance and feedback to peers when applicable
  • This position is 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 7 : 00am 6 : 00pm AST.

    It may be necessary, given the business need, to work occasional overtime or weekends.

    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 :

  • Currently possess one of the following credentials : Valid, active and unrestricted RN license for Puerto Rico and / or US
  • Intermediate Windows PC navigation proficiency or higher and ability to navigate in multiple systems
  • Knowledge of Microsoft Office including Word, PowerPoint, Excel, and Outlook (create / edit / save / send documents and emails)
  • Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)
  • Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance
  • Preferred Qualifications :

  • Experience working in a team atmosphere in a production driven environment with quality audit standards
  • Investigational and / or auditing experience, including government and state agency auditing
  • NCLEX certification
  • Experience of UHC platforms COSMOS, Facets and CPW and / or working with medical terminology or coding
  • Experience with Fraud, Waste & Abuse or Payment Integrity
  • Strong medical record review experience
  • Knowledge of health insurance business, industry terminology, and regulatory guidelines
  • To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies now require all employees to disclose COVID-19 vaccination status prior to beginning employment.

    In addition, some roles require full COVID-19 vaccination as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance.

    Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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