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Appeals Coder/Clinical Validation Nurse - National Remote

Company: UnitedHealth Group
Location: Goodyear
Posted on: March 18, 2023

Job Description:

You'll enjoy the flexibility to telecommute from anywhere within the U.S. 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. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work. SM

The Appeals Coder/Clinical Validation (CV) Nurse is part of a dynamic team that is responsible for crafting strongly defensible appeals, by leveraging critical thinking skills, for the benefit of our clients. This position leverages clinical and/or coding experience and performs medical record reviews, clinical information extraction, and support the development of appeal letters while ensuring quality and efficiency. S/he utilizes clinical data and/or coding guidelines to support defensible and accurate appeals assuring properly assigned diagnostic related grouping (DRG). The Appeals Coder/CV Nurse assures that the most accurate and descriptive codes from the listings of International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification and Procedure Coding System (ICD-9 and 10, CM and PCS) American Medical Association Current Procedural Terminology (CPT) Coding system, and Healthcare Common Procedure Coding System (HCPCS) codes supporting the patient's treatment have been applied to a provider claim. The Appeals Coder/CV Nurse is a company focused self-directed, motivated individual who is able to function independently in a fast paced and continuously evolving department. S/he works collaboratively with physicians, Operations, Intake, and leadership; as well as other departments within OPAS. The individual in this role will work directly with the Appeals leadership and team, they will need to be able to work independently and utilize the guidance provided. The Appeals Coder/CV Nurse will check the accuracy and thoroughness of their appeal prior to completing their case.

This position is full-time. Employees are required to work our normal business hours of 7:30am - 4:30pm (adhering to EST zone preferably). It may be necessary, given the business need, to work occasional overtime or weekends.

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

Primary Responsibilities:

  • Accurately and efficiently review and extract pertinent case details from patient medical records; and craft strongly defensible appeal letters per process instructions and the department's/company's guidance
  • Complete their case within the time expectations while providing high quality reviews.
  • Perform their job functions, adhering to both Optum and OPAS policies and procedures, which include but are not limited to the following:
    • Arrive to work on time and comply to scheduling expectations
    • Adhere to company policies and procedures regarding scheduled arrival and break times as well as Holiday commitments and time off expectations
    • Maintain accurate account of time off in Verint and HR Direct as per policy guidelines
    • Submit time off requests, temporary schedule changes, schedule adjustments, and/or report any scheduling discrepancies/errors per policy and procedure guidelines and/or report any scheduling discrepancies/errors per policy and procedure guidelines
    • Work in OPAS clinical database/clinical data entry programs
      • Use OPAS IT platforms to enter clinical and coding information as defined by the company policies and procedures
      • Maintain proficient knowledge of all programs utilized by the Appeals Team and other departments as needed
      • Promptly report any IT issues to the Service Desk; and to the supervisory staff as needed
      • Ability to extract pertinent clinical information and/or identify pertinent documentation to support diagnosis/procedure billing codes
      • Ability to support the development of appeal letters ensuring correct grammar, spelling, spacing and other formatting details
      • Compile a clear and concise clinical summary of each case based on review of the medical record.
      • Support an appeal position by:
        • Selecting an appropriate, supportable appeal arguments from evidence-based, peer reviewed medical literature as provided and/or:
        • Interpreting and utilizing ICD-9 and 10, CM and PCS, CPT coding system and HCPCS guidelines
        • Recommend changes to coding which will retain, lessen or increase financial impact when analysis of chart indicates opportunities
        • Educate clients on correct coding and compliance for best practices
        • Participate in Administrative Law Judge (ALJ) hearings, as trained, to defend client coding which can include extensive education to the judge on national coding practices and guidelines, and clinical information from the patient's medical record
        • Appropriately relate clinical information from the medical record to the selected appeal arguments and/or coding guidelines
        • Participate in one-to-one meetings with direct supervisor regarding progress, performance, and metrics.
        • Maintain ongoing professional communication with supervisory team and appeal letter reviewers regarding appeal letter feedback
        • Maintain up to date working knowledge of OPAS policies and protocols
        • Participate in all communications, educational opportunities, interdepartmental news, meetings, etc. as requested
        • Complete productivity requirements while maintaining quality expectations
        • Process appeals in a timely manner assuring due dates and turnaround time standards are maintained.
        • Maintain or exceed productivity and quality expectations o Will participate in productivity and quality review meetings upon request from their direct supervisor
          • Report any issues which may impact productivity or quality to their direct supervisor
            • IT issues, external issues, etc.
            • Impart confidential information appropriately per HIPAA regulations and company requirements and will follow the HIPAA policies
              • Impart confidential information appropriately per HIPAA regulations and company requirements
              • Identify instances of potential HIPPA violations and notify the appropriate staff per company policies and procedures
              • Maintain a secure working environment following the company's security policies and procedures
              • Performs other related duties, tasks, and processes as required by the leadership team
              • Interdepartmental collaboration
                • Work in collaboration with other departments to ensure minimum case data is provided to complete reviews as defined by OPAS processes
                • Assist with identification and correction of inaccurate and incomplete information
                  • Submit potential HIPPA issues per OPAS process
                  • Assist other departments as the business needs dictate
                  • Provide ongoing support to other department team members
                  • Education, Projects, and Meetings:
                    • Attend company, team, and individual meetings as directed
                    • Complete E- Learning courses per policy
                    • Participate in additional training and/or projects under the direction of the leadership team
                      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:
                      • High School diploma / GED (or higher)
                      • 1+ years of Inpatient Hospital Coding Experience
                      • 1+ years of DRG methodology
                      • 3+ years of outpatient coding experience
                      • One of the following Coding Certifications - CCS, CCS-P, CPC-H, CPC, RHIT, RHIA, CDIP, CCDS
                      • Mastery level knowledge of AHA Coding Clinic for ICD-9-CM and ICD-10
                      • Medicare/Medicaid Experience
                      • Auditing experience
                      • High degree of computer proficiency including typing skills (minimum of 45 wpm)
                      • Experience with Microsoft Office Suite and software, internet navigation and utilization
                      • Ability to work 7:30am - 4:30pm (adhering to EST zone preferably)
                        Preferred Qualifications:
                        • Bachelor's Degree (or higher)
                        • Active RN license as applicable
                        • Understanding of (and complies with) HIPAA confidentiality requirements
                        • Experience presenting to executive-level (i.e., Judge, Attorney, etc.) - preferably legal professionals
                          Telecommuting Requirements:
                          • 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:
                            • Demonstrate critical thinking and analytical skills
                            • Ability to establish priorities, be self-motivated, work independently, and follow instructions with supervision and structure
                            • Positive attitude and the ability to function as a collaborative team member . click apply for full job details

Keywords: UnitedHealth Group, Goodyear , Appeals Coder/Clinical Validation Nurse - National Remote, Healthcare , Goodyear, Arizona

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