RN DRG Validation Specialist - Remote

Company: UnitedHealth Group
Location: Eden Prairie
Posted on: March 15, 2023

Job Description:

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.

Energize your career with one of Healthcare's fastest growing companies.

You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it's a dream that definitely can come true. Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.

This opportunity is with one of our most exciting business areas: Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 5 leader.

Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.

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

Primary Responsibilities:

--- Investigate, review, and provide clinical and / or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. This could include Medical Director / physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
--- Perform clinical coverage review of claims, which requires interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns
--- Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing
--- Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, and discharge disposition, in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance
--- Must be fluent in application of current Official Coding Guidelines and Coding Clinic citations, in addition to demonstrating working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments
--- Solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment
--- Writes clear, accurate and concise rationales in support of findings
--- Identify aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommend providers to be flagged for review
--- Maintain and manages daily case review assignments, with a high emphasis on quality
--- Provide clinical support and expertise to the other investigative and analytical areas
--- Will be working in a high-volume production environment that is matrix drive

You'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:

--- Unrestricted RN (registered nurse)
--- CCS/CIC or will obtain within 6 months of hire
--- 3+ years of acute care coding experience Inpatient facility DRG/Clinical Documentation Improvement experience (coding or auditing)
--- Experience with ICD - 10 - CM coding
--- Experience with ICD - 10 - PCS coding
--- Knowledge of MS-DRG and/or APR-DRG payment methodologies

Preferred Qualifications:

--- 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
--- Investigation and / or auditing experience
--- Knowledge of health insurance business, industry terminology, and regulatory guidelines

Soft Skill:

--- Ability to use a Windows PC with the ability to utilize multiple applications at the same time

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 high - speed internet access

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New York, Rhode Island or Washington residents is $67,800 to $133,100. 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.

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

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. 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.

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