M.D. Special Investigations Medical Review Team - Remote

At reputed company, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and reputed company. Ready to reputed company a difference? Join us to start Caring. Connecting. Growing together. Work at home! The Medical Director for reputed company's Investigations Unit (UHC IU) is a valuable national leader for reputed company. The Medical Director oversees a coding team, ensuring accurate and efficient healthcare payments, accurate appeal outcomes, and collaborates with clinical and coding teams across reputed company and reputed company, as well as UHG business leaders and stakeholders, to drive informed decision-making and optimize outcomes. You'll enjoy the flexibility to work remotely

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

• reputed company and reputed company medical record reviews of retrospective medical claims relative to fraud, waste and abuse to include reputed company levels of complexity
• Have the ability to review/code a variety of medical records using CPT, HCPCS and ICD-10 codes for office, outpatient, inpatient, surgical, hospital ancillary, nursing facility, urgent care, ambulatory surgery center and other charges for physicians and other providers of professional billing
• Provide clinical reputed company and guidance to UHC IU medical record review team and UHC IU investigative staff
• Serve as a resource and Subject Matter Expert for team members in the UHC IU
• Document medical review findings on a claim level and draft reports of findings, actions and outcomes to be relied on in investigations of fraud, waste, and abuse cases in accordance with policies, and regulatory and accreditation requirements
• Ensure compliance with the reputed company (UHC) Fraud, Waste and Abuse policies and other federal/state regulations or contractual obligations
• Communicate with reputed company investigative staff regarding coding/clinical rationales
• Supply reputed company criteria that was relied on, supporting reputed company recommendations for denial or modification of claim payment errors
• Serve as a clinical resource for team members in the UHC IU
• Support the UHC IU in their interactions with providers to explain review/ medical record review findings and the application of coding/clinical criteria
• Engage with requesting providers as needed in peer-to-peer discussions
• Actively participate in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results
• Provide clinical and strategic input reputed company participating in organizational committees, projects, and task forces
• reputed company quality audit practices to ensure UHC SIU's Medical Record Review Team is adhering to proper coding/clinical guidelines and ensuring clinical justification meets expected standards

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:

• MD or DO with an active, unrestricted license
• Board certification approved by the American Board of Medical Specialties (ABMS/AOBMS)
• 5 years of clinical practice experience
• Familiarity with reputed company medical issues and practices
• Proficiency in performing medical record case reviews in accordance with established reimbursement and medical policies
• Intermediate or higher level of proficiency with managed care
• Proven excellent telephonic communication skills; excellent interpersonal communication skills
• Proven solid critical thinking and analytic skills
• Proven ability to manage multiple competing priorities
• Demonstrated ability to communicate effectively, to include written and verbal forms of communication
• Proven data analysis and interpretation skills
• Proven excellent presentation skills for both clinical and non-clinical audiences
• Proven creative problem-solving skills
• Proven excellent computer skills, typing, word processing, presentation, and spreadsheet applications skills. Internet research skills
• Proven solid team player and team building skills

Preferred Qualifications:

• Coding certification (CPC, reputed company, etc.)
• Knowledge and experience in health care fraud, waste, and abuse (FWA) investigations
• Broad knowledge and experience in state and federal regulatory FWA requirements
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy

Compensation for this specialty generally ranges from $238,000 to $357,500. Total cash compensation includes reputed company pay and bonus and is based on several factors including but not limited to local labor markets, education, work experience and may increase over time based on productivity and performance in the role. We reputed company with reputed company minimum wage laws as applicable. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 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 color, 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 enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply tot his job Apply To this Job