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. Join Optum Serve as a Payment Integrity Clinical Review Specialist. Optum Serve helps federal agencies and communities across the nation tackle some of the biggest challenges in health care. We help our clients and the communities they serve to prevent, prepare for, respond to, and recover from emergencies and long-term public health challenges. Optum Serve's Technology Services business unit focuses on health information technology and how to further federal customers' missions by continually looking for ways to increase efficiency and thereby, lower costs. With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Join Optum Serve's Technology Services team to help protect our nation's most critical federal programs. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all 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: • Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations • Conduct provider claim and clinical audits, preparing clinical review summaries with recommendations and proper citations and resources • Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse • Support investigation and clinical discussions with federal law enforcement • Apply industry, state, and federal regulations and guidelines • Assess findings to detect patterns of fraud, waste, and abuse • Make accurate claim decisions based on VA policies, payment rules, coding guidelines, and clinical judgment 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.
Optum Home & Community Care is part of UnitedHealth Group and provides telephonic case management services to help members navigate the health care system and access support services. As an RN Case Manager, you would assess members' health status, identify gaps in treatment plans, establish care goals, coordinate with multidisciplinary teams including mental health clinicians, provide patient education and coaching, make referrals to community resources, and facilitate transitions between care settings—primarily through phone calls in a high-volume customer service environment.
