Clinical Investigator
UnitedHealth Group is an innovative leader in the health and well-being industry, serving more than 55 million Americans. Through our family of companies, we contribute outstanding clinical insight with consumer-friendly services and advanced technology to help people achieve optimal health.
Position Description:
Positions in this function are responsible for investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers and government entities. May include initiating telephone calls to members, providers and other insurance companies. Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance. May conduct contestable investigations to review medical history. May monitor large claims including transplant cases.
Primary Responsibilities:
- Investigates, reviews, and provides clinical expertise in the application of medical and reimbursement policies within the claim adjudication process through file review, Medical Director/physician consultations, and interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information.
- Performs prospective clinical coverage and coding review of fraudulent and abusive claims.
- Performs clinical coverage review of post-service claims, which requires interpretation of state and federal mandates, applicable benefit language, medical reimbursement policies and consideration of relevant clinical information on claims with aberrant billing patterns.
- Identifies aberrant billing patterns and trends, evidence of abuse fraud, and inappropriate patterns of treatment
- Performs clinical coding review to ensure accuracy of medical coding, and underlying coverage of new emerging services, procedures, or diagnostic testing.
- Utilizes clinical expertise and judgment to determine correct coding billing.
- Participates in training of new staff, and serves as a clinical resource to other areas within the clinical investigative team.
- Identifies and develops training needs in collaboration with office trainers and development coaches.
- Ensures consistent administration of Medical Claim Review, and standard medical necessity determinations for claims with aberrant billing patterns.
- Analyzes clinical investigation and provides written or verbal education with health
Requirements:
OptumInsight is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
OptumInsight is one of the largest and fastest growing health information companies. We specialize in improving the performance of the health system by providing analytics, technology and consulting services that enable better decisions and results. We integrate workflow solutions that deliver data in real-time, and create actionable insights - processing health information that relates directly to and affects one in four patients in the U.S., one in every three Medicaid dollars and one in every five emergency room visits. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation Performance.
What can YOU do with the right information? At OptumInsight, the possibilities and the impact are limitless. No matter what your role is at OptumInsight, you'll be empowered to ask more questions, develop better solutions and help make the health care system greater than ever. It's always fresh. It's always exciting. And it's never been more important.