Program Integrity Clinical Compliance Auditor

This position is Remote in the state of Massachusetts. You will have the flexibility to work remotely
* as you take on some tough challenges.

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. Ready to help us deliver results that improve lives?

Join us to start Caring. Connecting. Growing together.

The Sr. 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 position will utilize information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations in order to document relevant findings.

The Sr. Recovery Resolution Analyst will conduct site visits and desk audits of provider claims, and medical and administrative records, to gather and analyze all necessary information to determine whether subject adhered to state and federal compliance policies, reimbursement policies, and contract compliance. The Sr. Recovery Resolution Analyst will present and discuss audit findings with client and input information into Optum audit workflow tools and the client's case tracking system.

Where applicable, the Auditor will support appeal and fraud investigation activities.

This position is full-time (40 hours/week), Monday
- Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of Monday thru Friday 8:00 am - 5:00 pm local time. It may be necessary, given the business need, to work occasional overtime.

We offer on the job training. The hours during training will be aligned with your schedule.

• Review medical and administrative records for audit/compliance review
• Travel to provider sites up to 25%/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

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.

• High School Diploma / GED or equivalent work experience
• Nurse licensure (RN or LPN) with a current, active, and unrestricted license in Massachusetts
• Must be 18 years of age OR older
• 2+ years of experience reviewing health care documentation in a clinical or administrative role
• Experience with MS Office Suite, specifically Word, PowerPoint, and Excel (including familiarity with basic formulas and data analysis)
• Must be willing to travel up to 25% within the state of Massachusetts as business needs dictate
• Must have a Valid Driver's license
• Ability to work full-time (40 hours/week), Monday
  - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal

• Clinical or administrative experience in long term care, for example, nursing facility care…