RN Clinical Reviewer (CPC Medical Coding Academy)
Not Disclosed•Full-TimeOn-site
location_onGranchina, Calle Guayama, 00917, United States
About Optum
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.
About the Role
Positions in this function investigate Optum Waste and Error stopped claims by gathering information, researching state and federal guidelines, and following internal procedures to determine the viability of the claim for further review in a production environment. You will perform clinical reviews of professional or facility claims against medical records to determine if the claim is supported or unsupported. Your work will involve examining, assessing, and documenting business operations to ensure data integrity, security, and process optimization. Additionally, you will investigate, recover, and resolve all types of claims for health plans, commercial customers, and government entities, ensuring adherence to compliance policies and reimbursement standards.
Hiring Process
Candidates must be proficient in both English and Spanish. Please note that an English proficiency assessment will be required after application.
Our Commitment to Diversity and Inclusion
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. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law. Qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status. UnitedHealth Group is a drug-free workplace; candidates are required to pass a drug test before beginning employment.
Work location
Work model: On-site
Granchina, Calle Guayama, 00917, United States
Key Responsibilities
- check_circleProvide clear and concise clinical logic to providers when necessary
- check_circleInvestigate, recover, and resolve claims for health plans, commercial customers, and government entities
- check_circleEnsure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- check_circleAttend monthly meetings with internal customer departments and provide feedback on team relationships
- check_circleMaintain required Coding Certificate and Nursing Licensure through continuing education and compliance hours
- check_circlePerform clinical review of professional and facility claims against medical records to determine claim support
- check_circleExamine and document business operations to ensure data integrity, security, and process optimization
- check_circleMaintain department-defined standards for productivity and accuracy in claim processing
Requirements
- verifiedCoding Certificate or Nursing Licensure (e.g., Puerto Rico Registered Nurse, CPC, CPC A, CIC, COC, CPMA, CCS)
- verifiedProficiency with Microsoft Suite
- verifiedAbility to work on-site
- verifiedAvailability Monday to Friday, 40 hours/week, 8am-7pm ATL
- verifiedProfessional proficiency in English and Spanish
Nice to Have
Experience working with medical claims platforms. Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting. Presentation or policy documentation experience. Proven knowledge of CMS and AMA coding rules specific to CPT, HCPCS. Proven knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations. Proven knowledge of Medicaid/Medicare Reimbursement methodologies. Proven working knowledge of the healthcare insurance/managed care industry. Proven working knowledge of medical terminology and claim coding.
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Frequently asked questions about RN Clinical Reviewer (CPC Medical Coding Academy) at UnitedHealth Group
What does a RN Clinical Reviewer (CPC Medical Coding Academy) at UnitedHealth Group do?expand_more
In this RN Clinical Reviewer (CPC Medical Coding Academy) at UnitedHealth Group role, you will provide clear and concise clinical logic to providers when necessary; investigate, recover, and resolve claims for health plans, commercial customers, and government entities; ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance; and attend monthly meetings with internal customer departments and provide feedback on team relationships.
What are the requirements for this RN Clinical Reviewer (CPC Medical Coding Academy) role?expand_more
UnitedHealth Group is looking for candidates who meet the following requirements: Coding Certificate or Nursing Licensure (e.g., Puerto Rico Registered Nurse, CPC, CPC A, CIC, COC, CPMA, CCS); Proficiency with Microsoft Suite; Ability to work on-site; Availability Monday to Friday, 40 hours/week, 8am-7pm ATL; and Professional proficiency in English and Spanish.
Where is the RN Clinical Reviewer (CPC Medical Coding Academy) role at UnitedHealth Group located?expand_more
RN Clinical Reviewer (CPC Medical Coding Academy) at UnitedHealth Group is based in Granchina, Calle Guayama, 00917, United States. This is a on-site role.
Is this RN Clinical Reviewer (CPC Medical Coding Academy) job remote, hybrid, or on-site?expand_more
UnitedHealth Group has listed this RN Clinical Reviewer (CPC Medical Coding Academy) role as on-site.
How much experience is required for this RN Clinical Reviewer (CPC Medical Coding Academy) role?expand_more
Candidates for RN Clinical Reviewer (CPC Medical Coding Academy) at UnitedHealth Group should have mid level.
What skills do you need for the RN Clinical Reviewer (CPC Medical Coding Academy) role at UnitedHealth Group?expand_more
Key skills for RN Clinical Reviewer (CPC Medical Coding Academy) at UnitedHealth Group include Microsoft Suite; English; Spanish; Puerto Rico Registered Nurse; Certified Professional Coder; CPC A; Certified Inpatient Coder; and Certified Outpatient Auditor.
What category does the RN Clinical Reviewer (CPC Medical Coding Academy) role belong to?expand_more
RN Clinical Reviewer (CPC Medical Coding Academy) at UnitedHealth Group is part of the healthcare & nursing job category on Recrutus.