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Associate Director of Clinical Audit Services - Telecommute

Company: UnitedHealth Group
Location: San Diego
Posted on: November 22, 2021

Job Description:

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

OptumCare is a network of health care providers in local markets whose mission is to help providers deliver the most effective and compassionate care to each patient they serve. OptumCare's primary focus is on doing the right things for patients, physicians, and the community. It uses an innovative service model focused on measuring what matters and increasing efficiency and performance while providing the highest level of customer service. This model allows OptumCare to make a difference each day by delivering highly personal, customized care management to its patients.

The Associate Director of Clinical Audit Services will play a critical role in coordination and completion of growth projects across various Optum Care Service Operation teams. With a core focus on Clinical Audit activities, you'll be engaged in a complex business model that prioritizes customer experience and innovative solutions through technology and service standards. As part of a team that provides solutions and value across a variety of Optum Care teams, it is critical that this role brings curiosity, growth mindset, and personal accountability to the work each day, showing up as flexible and productive in the face of change or obstacles. The successful candidate can build trust and rapport with individuals as they work and is passionate about driving plans into action.

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

Primary Responsibilities:

  • Investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical records review
  • Serve as a Subject Matter Expert (SME), performing medical record reviews to include quality audits, as well as validation of accuracy and completeness of all coding elements, and medical necessity reviews
  • Responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development
  • Serves cross-functionally with Medical Directors, and sometimes Utilization Management, as well as other internal teams to assist in identification of overpayments
  • Serves as a SME for all Payment Integrity functions to include both Retrospective Data Mining, as well as Pre-Payment Cost Avoidance
  • Identifies trends and patterns with overall program and individual provider coding practices
  • Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable opportunity
  • Performs all related duties as assignedYou'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:
    • Bachelor's Degree or equivalent work experience
    • Completion of an accredited Registered Nurse (RN) Program
    • Certified Professional Coder (CPC), or willingness to obtain within 6 months from hire date
    • 5+ years of experience in the health insurance industry
    • 3+ years of experience with health insurance claims
    • 2+ years of experience with medical records review/auditing
    • 2+ years of experience in management and/or progressive leadership
    • Proficiency in performing financial analysis/audit including statistical calculation and interpretation
    • Proficiency in various claims payment methodologies; to include capitation, fee-for-service, DRG, percent-of-charge, and OPPS
    • Proficiency using Microsoft Office: Word, Excel (data analysis, sorting/filtering, pivot tables), PowerPoint (prepare formal presentations and training), Visio (develop workflow processes)
    • Experience interpreting provider contractual agreements
    • 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 compliancePreferred Qualifications:
      • Certified Professional Coder (CPC), Certified Professional Compliance Officer (CPCO), Accredited HealthCare Fraud Investigator (AHFI)
      • Experience managing a comprehensive portfolio of programs
      • Demonstrated ability to gather and analyze information from multiple sources and use to form a cohesive and comprehensive recommendation or problem solution
      • Experience using claims platforms such a UNET, Pulse, NICE, Facets, Diamond, etc.
      • Experience launching and managing new healthcare initiatives/plans
      • Experience with CES (Claims Editing System) or other claims clinical editing programs
      • Proficiency in various claims payment methodologies; to include capitation, fee-for-service, DRG, percent-of-charge, and OPPS
      • Experience with Fraud, Waste, & Abuse (FWA) programs, or working within a Special Investigations Unit (SIU)
      • Proficiency in performing financial analysis/audit including statistical calculation and interpretation
      • Proficiency in various claims payment methodologies; to include capitation, fee-for-service, DRG, percent-of-charge, and OPPS
      • Proficiency using Microsoft Office: Word, Excel (data analysis, sorting/filtering, pivot tables), PowerPoint (prepare formal presentations and training), Visio (develop workflow processes)
      • Experience with public speaking and presenting to large audiences, including Executives and Medical Directors
      • Experience interpreting provider contractual agreementsTo 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.

        Careers at OptumCare. We're on a mission to change the face of health care. As the largest health and wellness business in the US, we help 58 million people navigate the health care system, finance their health care needs and achieve their health and well-being goals. Fortunately, we have a team of the best and brightest minds on the planet to make it happen. Together we're creating the most innovative ideas and comprehensive strategies to help heal the health care system and create a brighter future for us all. Join us and learn why there is no better place to do your life's best work.(sm)

        OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

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

        Colorado, Connecticut or Nevada Residents Only : The salary range for Colorado, Connecticut and/or Nevada residents is $94,500 to $171,700. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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.

        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.

        Job Keywords: Associate Director of Clinical Audit Services, Optum, OptumCare, UHG, UnitedHealth Group, Telecommute, Telecommuter, Telecommuting, Work at Home, Work from Home, Remote

Keywords: UnitedHealth Group, San Diego , Associate Director of Clinical Audit Services - Telecommute, Healthcare , San Diego, California

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