IBR Clinical Appeals Reviewer – Remote

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 Itemized Bill Review (IBR) Clinical Appeals Reviewer will analyze and respond to client and/or hospital claim review appeal inquiries. Handles medical record review, analyzes data, and completes the response resolution for clients and the business unit. Must utilize expertise in auditing to review and provide response to appeals. We are seeking self-motivated, solution-oriented and skilled problem solver who provides clinical reviews with written documentation under tight deadlines. This position is full-time, Monday – Friday. Employees are required to work our normal business hours of 8:00am – 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Analyze scope and resolution of IBR Appeals Respond to Level one, two or higher appeals Perform complex conceptual analyses Identifies risk factors, comorbidities’, and adverse events, to determine if overpayment or claim adjustment is needed. Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions Researches and prepares written appeals Exercises clinical and/or coding judgment and experience Collaborates with existing auditors, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims. Navigates through web-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel Serve as a key resource on complex and / or critical issues and help develop innovative solutions Define and document / communicate business requirements