Lead and supervise a small audit team to review medical and administrative records for fraud, waste, and compliance. Conduct desk audits and up to 10% site visits, present findings to clients, enter audit data into electronic systems, support appeals and investigations, and participate in dispute reviews and hearings.
Requisition Number: 2369905
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.
The Audit Team Lead will be responsible for playing a leadership role in 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 Audit Team Lead will lead 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 Audit Team Lead will present and discuss audit findings with clients and input information into Optum audit workflow tools and the client's case tracking system. Where applicable, the Audit Team Lead will support appeal and fraud investigation activities. Finally, the Audit Team Lead will supervise and support the work of other Auditors in all the responsibilities noted here.
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 8:00 am - 5:00 pm EST. It may be necessary, given the business need, to work occasional overtime.
We offer 8 weeks of paid training. The hours during training will be 8:00 am to 5:00 pm EST, Monday - Friday.
If you are located in Massachusetts, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
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:
Preferred Qualifications:
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, 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.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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.
The Audit Team Lead will be responsible for playing a leadership role in 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 Audit Team Lead will lead 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 Audit Team Lead will present and discuss audit findings with clients and input information into Optum audit workflow tools and the client's case tracking system. Where applicable, the Audit Team Lead will support appeal and fraud investigation activities. Finally, the Audit Team Lead will supervise and support the work of other Auditors in all the responsibilities noted here.
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 8:00 am - 5:00 pm EST. It may be necessary, given the business need, to work occasional overtime.
We offer 8 weeks of paid training. The hours during training will be 8:00 am to 5:00 pm EST, Monday - Friday.
If you are located in Massachusetts, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
- Supervise and support the work of other Auditors as detailed below
- Review medical and administrative records for audit/compliance review
- Travel to provider sites up to 10%/month to collect records and engage with providers
- Present and participate in discussions with clients 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:
- Active nurse licensure (RN or LPN) in MA
- 1+ years of experience reviewing health care documentation in a clinical or administrative role
- 1+ years of basic experience with Excel, including familiarity with basic formulas and data analysis
- Ability to work full time (40 hours/week), Monday - Friday, with flexibility for occasional overtime or weekend needs
- Located and able to travel up to 10% within the state of Massachusetts
Preferred Qualifications:
- Clinical or administrative experience in long term care, for example, nursing facility care delivery/administration and/or community-based LTC service programs like Home Health
- Experience in claim processing, healthcare provider information, and healthcare billing practices
- Experience working in a remote/telecommute workspace
- Working knowledge of medical terminology and claim coding
- Familiarity with Medicaid program and/or billing requirements
- Familiarity with CPT-4, HCPCs and ICD-10 code terminology
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
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.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, 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.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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