Integrity Clinical Review Specialist - Fraud Waste and Abuse - Optum Serve - Remote

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.

Join Optum Serve as a Payment Integrity Clinical Review Specialist
. Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. We help our clients and the communities they serve to prevent, prepare for, respond to, and recover from emergencies and long-term public health challenges. Optum Serve’s Technology Services business unit focuses on health information technology and how to further federal customers’ missions by continually looking for ways to increase efficiency and thereby, lower costs.

With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Join Optum Serve’s Technology Services team to help protect our nation’s most critical federal programs.

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

For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities:

• Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations
• Conduct provider claim and clinical audits, preparing clinical review summaries with recommendations and proper citations and resources
• Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse
• Support investigation and clinical discussions with federal law enforcement
• Apply industry, state, and federal regulations and guidelines
• Assess findings to detect patterns of fraud, waste, and abuse
• Make accurate claim decisions based on VA policies, payment rules, coding guidelines, and clinical judgment

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:

• Active, unrestricted RN license in state of residence
• Certified Professional Coder (CPC)
• 3+ years of experience in a position processing medical claim auditing, payment integrity, and investigating fraud, waste, and abuse
• 2+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment
• 2+ years of clinical medical/surgical experience
• 1+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity
• Proven to be a Critical thinker

Preferred Qualifications:

• Graduate Degree
• Certified Coding Specialist
• Certified Fraud Examiner
• Experience training and coaching other team members
• Experience with Facets, PGBA, or other claims processing systems
• An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare…