DRG/Clinical Validation Auditor RN,

$34.23 - $61.15 / hour

$10,000 SIGN ON BONUS FOR EXTERNAL APPLICANTS

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

In this position as a Clinical DRG RN auditor, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings.

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

Primary Responsibilities

Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification
Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance
Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments
Perform clinical coding review to ensure accuracy of medical coding and utilize clinical expertise and judgment to determine correct coding and billing
Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment
Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics
Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly
Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements
Maintain and manage daily case review assignments, with a high emphasis on quality
Provide clinical support and expertise in the other investigative and analytical areas
Work in a high-volume production environment that is matrix driven

What Are The Reasons To Consider Working For UnitedHealth Group? Put It All Together - Competitive Base Pay, a Full And Comprehensive Benefit Program, Performance Rewards, And a Management Team Who Demonstrates Their Commitment To Your Success. Some Of Our Offerings Include

Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
Medical Plan options along with participation in a Health Spending Account or a Health Saving account
Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
401(k) Savings Plan, Employee Stock Purchase Plan
Education Reimbursement
Employee Discounts
Employee Assistance Program
Employee Referral Bonus Program
Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
More information can be downloaded at: http://uhg.hr/uhgbenefits

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

Associate's Degree (or higher)
Unrestricted RN (Registered Nurse) license
CCS/CIC or willing to obtain certification within 6 months of hire
3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers

Preferred Qualifications

Experience with prior DRG concurrent and/or retrospective overpayment identification audits
Experience working with Utilization Management
Experience with readmission reviews of claims
Experience with DRG encoder tools (ex. 3M)
Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry
Healthcare claims experience
Managed care experience
Knowledge of health insurance business, industry terminology, and regulatory guidelines

Soft Skills

Ability to use a Windows PC with the ability to utilize multiple applications at the same time
Ability to work independently in a remote environment and deliver exceptional results
Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail
Excellent time management and work prioritization skills

Physical Requirements And Work Environment

Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer
Have a secluded office area in which to perform job duties during the work day
Have reliable high-speed internet access and a work environment free from distractions
All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and 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, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

#RPO #GREEN #RPOLinkedin

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