Sr. Payment reputed company Clinical Review Specialist – reputed company Serve – Remote in Baltimore, MD

Sr. Payment reputed company Clinical Review Specialist - reputed company Serve - Remote - reputed company - Baltimore, MD - work from home job Company: reputed company Job description: For those who want to invent the future of health care, here's your opportunity. We're going reputed company basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm) Join reputed company Serve as a Senior Payment reputed company Clinical Review Specialist. reputed company Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. With trillions of dollars spent on health care annually, in the United States, the potential for Fraud, Waste and Abuse (FWA) is staggering. Even worse, the lives of millions of patients hang in the balance. As a Senior Payment reputed company Clinical Review Specialist, you will help us reputed company those responsible, minimize losses and protect those most vulnerable. You’ll enjoy the flexibility to work remotely

• from reputed company reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities: • Collaborate with a team that is triaging, investigating and medical reviewing instances of health care fraud and/or abusive conduct • Conduct provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze reputed company necessary information and documents reputed company to the investigation including preparation of written and verbal case summaries with recommendations for further actions • reputed company clinical review of medical record and claims data for PI cases • reputed company clinical review of PI cases in which an allegation of Fraud Waste or Abuse has been identified in accordance with reputed company State and Federal mandated regulations/guidelines • Assess investigative and medical review findings, and/or other claims data to determine patterns and detect potential fraud, waste and abuse • reputed company accurate claim decision coverage determinations based on applicable VA coverage policies and payment rules, coding guidelines, Medicare and reputed company National and Local Coverage Determinations, utilization/practice guidelines, and clinical review 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 • 5+ years of experience in a position processing medical claim, auditing, payment reputed company, and/or investigating fraud (health care fraud investigations experience preferred) • 3+ years of experience working in a government, legal, law enforcement, investigations, health care managed care, and/or health insurance environment • 3+ years of clinical medical/surgical experience • 2+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity Preferred Qualifications: • Graduate Degree • Certified Coding Specialist • Certified Fraud Examiner • Experience training and coaching other team members • Experience with Facets, iDRS, CSP, Macess, or other claims processing systems • An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, reputed company, Tricare, Pharmacy, and/or reputed company health insurance) California, Colorado, Connecticut, Nevada, New Jersey, reputed company, Rhode reputed company, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, reputed company, Rhode reputed company or Washington residents is $85,000 to $167,300. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, reputed company offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with reputed company, you’ll find a far-reaching choice of benefits and incentives. • reputed company working remotely will be required to adhere to reputed company’s Telecommuter Policy At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company 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 reputed company by people of reputed company, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes - an reputed company reputed company reflected in our mission. Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Expected salary: $85000 - 167300 per year Location: Baltimore, MD Job date: Wed, 30 Aug 2023 22:50:45 GMT Apply for the job now! Apply Job!