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Healthcare Compliance Auditor - Boston, MA - 2203583

Optum

Optum

Legal
Boston, MA, USA
Posted on Friday, December 15, 2023

If you are located within the state of Massachusetts, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.

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.

The Healthcare Compliance Auditor 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 to document relevant findings. The Auditor 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 Auditor 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, Monday – Friday. Employees are required to work our normal business hours of 7:00am – 3:30pm or 8:00am – 4:30pm EST.

Our office is located at 1325 Boylston St. Boston, MA. Employees will be required to work some days onsite and some days from home.

We offer 3 weeks of on-the-job training. The hours of the training will be aligned with your schedule.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

  • 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 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

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:

  • Must be 18 years of age or older.
  • 1+ years of experience reviewing health care documentation in a clinical or administrative role.
  • Nurse licensure (RN or LPN) or Medical Coder certification or Auditor Certification.
  • Ability to travel up to 25% within the state of Massachusetts.
  • Experience with Microsoft Excel (basic formulas and data analysis)
  • Telecommuting is not to be used as a substitute for child or dependent care. Must establish regular child or dependent care arrangements while telecommuting (If applicable).
  • Ability to work full-time, Monday – Friday. Employees are required to work our normal business hours of 7:00am – 3:30pm or 8:00am – 4:30pm EST

Preferred Qualifications:

  • Clinical or administrative experience in long term care, for example, nursing facility care delivery/administration and/or community-based long term care service programs like Home Health.
  • Familiarity with Medicaid program and/or billing requirements.
  • Working knowledge of medical terminology and claim coding.
  • Previous experience in claim processing and healthcare billing practices.
  • Familiarity with CPT-4, HCPCS and ICD-10 code terminology.
  • Experience working in a remote/telecommute workspace.

Telecommuting Requirements:

  • Reside within the state of Massachusetts
  • Required to have a dedicated work area established that is separated from other living areas and provides information privacy
  • Ability to keep all company sensitive documents secure (if applicable)
  • Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

Soft Skills:

  • Strong written and verbal communications skills.
  • Strong customer service skills.

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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