Program Integrity Clinical Compliance Auditor

Overview 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. This position is remote in Massachusetts with the flexibility to work remotely. Position The Senior 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 role will utilize information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations to document relevant findings. The Senior Recovery Resolution Analyst will conduct site visits and desk audits of provider claims and medical and administrative records to gather and analyze information to determine whether subjects adhered to state and federal compliance policies, reimbursement policies, and contract compliance. The analyst will present and discuss audit findings with clients and input information into Optum audit workflow tools and the client\'s case tracking system. Where applicable, the analyst will support appeal and fraud investigation activities. Schedule and Work Environment This is a full-time position (40 hours/week), Monday through Friday. Flexibility to work any of the 8-hour shift schedules during normal business hours (8:00 am – 5:00 pm local time) is required. Occasional overtime may be necessary. Training and Development On-the-job training is provided with hours during training aligned to your schedule. Primary Responsibilities Review medical and administrative records for audit/compliance review Travel to provider sites up to 25% per 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 Demonstrated written and verbal communications skills Demonstrated customer service skills Required Qualifications Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts Valid Driver\'s license 2+ years of experience reviewing health care documentation in a clinical or administrative role Experience with MS Office Suite (Word, PowerPoint, Excel) including basic formulas and data analysis Willingness to travel up to 25% within Massachusetts as business needs dictate Ability to work full-time (40 hours/week), Monday - Friday, with flexibility to work the 8-hour shift schedule; occasional overtime may be necessary Preferred Qualifications Clinical or administrative experience in long term care, nursing facility care delivery/administration, or community-based LTC service programs (e.g., Home Health) Experience in claim processing, healthcare provider information, and healthcare billing practices Experience working in a remote/telecommute workspace Familiarity with Medicaid program and/or billing requirements Working knowledge of medical terminology and claim coding (CPT-4, HCPCS, ICD-10) Telecommuting Requirements Must reside in the state of Massachusetts Ability to keep all company sensitive documents secure (if applicable) Dedicated work area established that is separated from other living areas and provides information privacy Must have access to high-speed internet connection or use an existing high-speed service *All employees working remotely will be required to adhere to UnitedHealth Group\'s Telecommuter Policy Compensation and Benefits Pay is based on factors including local labor markets, education, work experience, and certifications. The hourly pay range for this role is $28.94 - $51.63 per hour based on full-time employment. Benefits include a comprehensive package, incentive and recognition programs, equity stock purchase and 401k contributions (eligibility applies). Equal Opportunity UnitedHealth Group is an Equal Employment Opportunity employer. We consider applicants without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, veteran status, or any other protected status. UnitedHealth Group is a drug-free workplace; candidates are required to pass a drug test before beginning employment. #J-18808-Ljbffr