Clinical Reviewer (Medical Coding Academy - CPC) - San Juan, PR
UnitedHealth Group
- San Juan, PR
- Permanent
- Full-time
- Clinical Case Reviews -75%
- Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported
- Maintain standards for productivity and accuracy. Standards are defined by the department
- Provide clear and concise clinical logic to the providers when necessary
- Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
- Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
- Investigate and pursue recoveries
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- Use pertinent data and facts to identify and solve a range of problems within area of expertise
- Other internal customer correspondence and team needs - 15%
- Attend and provide feedback during monthly meetings with assigned internal customer department
- Provide continuous feedback on how to improve the department relationships with internal team members and departments
- Continuing education - 10%
- Keep up required Coding Certificate and/or Nursing Licensure
- Complete compliance hours as required by the department
- Coding Certificate or Nursing Licensure, for example:
- Puerto Rico Registered Nurse
- Certified Professional Coder (CPC) + CPC A
- Certified Inpatient Coder (CIC)
- Certified Outpatient Auditor (COC)
- Certified Professional Medical Auditor (CPMA)
- Certified Coding Specialist (CCS)
- Proficient with computers, including Microsoft Suite of products
- Willing or availability to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL
- Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)
- Experience working with medical claims platforms
- Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting
- Presentation or policy documentation experience
- Knowledge of CMS and AMA coding rules specific to CPT, HCPCS
- Knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations