- Clinical Case Reviews -75% Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupportedMaintain standards for productivity and accuracy. Standards are defined by the departmentProvide clear and concise clinical logic to the providers when necessaryExamine, assess, and document business operations and procedures to ensure data integrity, data security and process optimizationInvestigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entitiesInvestigate and pursue recoveriesEnsure adherence to state and federal compliance policies, reimbursement policies, and contract complianceUse pertinent data and facts to identify and solve a range of problems within area of expertise
- Other internal customer correspondence and team needs - 15% Attend and provide feedback during monthly meetings with assigned internal customer departmentProvide continuous feedback on how to improve the department relationships with internal team members and departments
- Continuing education - 10% Keep up required Coding Certificate and/or Nursing LicensureComplete compliance hours as required by the department
- Coding Certificate or Nursing Licensure, for example: Puerto Rico Registered NurseCertified Professional Coder (CPC) + CPC ACertified Inpatient Coder (CIC)Certified Outpatient Auditor (COC)Certified Professional Medical Auditor (CPMA)Certified Coding Specialist (CCS)
- Proficient with computers, including Microsoft Suite of products
- Willing or availability to work from Monday to Friday, 40 hours per week during our business operating hours of 8am - 7pm ATL
- Professional proficiency in both English and Spanish (Please note that an English proficiency assessment will be required for this position)
- Experience working with medical claims platforms
- Medical record coding experience with experience in Evaluation and Management Services in the outpatient/office setting
- Presentation or policy documentation experience
- Knowledge of CMS and AMA coding rules specific to CPT, HCPCS
- Knowledge of CMS Coverage, Federal and State Statues, Rules and Regulations
- Knowledge of Medicaid/Medicare Reimbursement methodologies
- Working knowledge of the healthcare insurance/managed care industry
- Working knowledge of medical terminology and claim coding
-
atom 34
hace 1 semana
Fresenius Medical Care, North America Caguas, Puerto Rico Permanent position, De jornada completaPURPOSE AND SCOPE: · Supports FMCNA's mission, vision, core values and customer service philosophy. Adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements. For a defined Area, responsible for supervising the overall operation, cond ...
-
Nurse Reviewer I
hace 1 semana
Elevance Health San Juan, Puerto Rico De jornada completaJob Description · : A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans. · Nurse Re ...
-
Community Management Intern
hace 1 semana
Walgreens Caguas, Puerto Rico De jornada completaJob Description · Job Objectives · Learn to provide an extraordinary customer experience in retail store setting. · Completes product returns, order voids, customer refunds, cash drops to the safe, and provides change as requested to cash registers. · Models and delivers a dist ...
-
Sr Mgr Clinical Education
hace 5 días
Fresenius Medical Care, North America San Juan, Puerto Rico Permanent position, De jornada completaPURPOSE AND SCOPE: · Directs the planning, implementation, and execution of clinical, quality, and customer service training programs to promote quality patient care and achievement of corporate goals, with adherence to policies and procedures using generational learning theorie ...
-
Reviewer - Therapy Services
hace 3 días
Elevance Health San Juan, Puerto Rico De jornada completaJob Description · : Reviewer - Therapy Services · Location: Within 50 miles of pulse point location · Hours: Monday - Friday from 9:30 am - 6:00 pm PST · The Reviewer -Therapy Services is responsible for the review of medical records to determine if requests for therapy s ...
-
Pharmacy Manager
hace 14 horas
Walgreens San Juan, Puerto Rico De jornada completaJob Description · Job Summary: · Provides pharmacy consulting services with empathy to patients regarding the effective usage of medications and awareness with drug interactions. Offers preventive and clinical healthcare services, including immunizations, diagnostic testing, an ...
-
Senior Clinical Quality RN
hace 6 días
UnitedHealth Group San Juan, Puerto Rico De jornada completaOptum 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 ...
-
Senior Clinical Quality RN
hace 5 días
UnitedHealth Group San Juan, Puerto Rico De jornada completaOptum 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 ...
-
Specialist, Coverage Determination
hace 3 días
abarca health San Juan, Puerto RicoWhat you'll do · In a few words... · Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning... · Providing high quality services to client and beneficiarie ...
-
Data Analyst, Government Programs
hace 5 días
abarca health San Juan, Puerto RicoWhat you'll do · In a few words... · Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning... · From managing day-to-day pharmacy network operations, dev ...
-
Client Advocate
hace 1 día
NFP San Juan, Puerto RicoThe Benefits Specialist is responsible for assisting Product and Client Managers, with the strategic flow and positioning of communication and data to and from the client and company departments. They serve as a liaison between the Company and its clients in assisting with servic ...
-
Senior Software Engineer
hace 5 días
El Comeback San Juan, Puerto Rico***El Comeback is a non-profit program from ConPRmetidos that attracts and retains professional talent for Puerto Rico-based jobs. Register at to get matched with professional opportunities on the island. Candidates' searches for positions posted by El Comeback are done on behal ...
-
Quality Technician
hace 5 días
TPR - Quality Caguas, Puerto RicoTerumo Medical Corporation (TMC) develops, manufactures, and markets a complete, solutions-based portfolio of high-quality medical devices used in a broad range of applications for numerous areas of the healthcare industry. TMC places a premium on providing customers with world-c ...
-
Referral Services Assistant
hace 5 días
Elevance Health San Juan, Puerto Rico De jornada completaJob Description · : Referral Services Assistant · Location: Remote, within 50 miles of an Elevance pulse point · Hours: Monday - Friday from 8:00 am - 5:00 pm P ST · The Referral Services Assistant is responsible for providing support to clinical team to facilitate the ...
-
Cardiothoracic Surgeon
hace 1 semana
Adelphi Medical Staffing San Juan, Puerto RicoSeeking a Cardiothoracic Surgeons to provide on-site Cardiothoracic Surgery services at a Medical Center in San Juan, Puerto Rico. The ideal candidate will possess a full & unrestricted license & is BC/BE by the ABTS. · Job Quick Facts: · • Ref#: IC-CTS-0122 · • Profession: Phys ...
-
Cardiothoracic Surgeon
hace 1 semana
Adelphi Medical Staffing San Juan, Puerto RicoJob Description · Seeking a Cardiothoracic Surgeons to provide on-site Cardiothoracic Surgery services at a Medical Center in San Juan, Puerto Rico. The ideal candidate will possess a full & unrestricted license & is BC/BE by the ABTS. · Job Quick Facts: · • Ref#: IC-CTS-0122 · ...
-
Team Leader
hace 1 semana
abarca health San Juan, Puerto RicoWhat you'll do · In a few words... · Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning... · Abarca's Service Operations team takes the charge by hand ...
-
Regulatory Affairs Manager
hace 1 día
Elevance Health San Juan, Puerto Rico De jornada completaJob Description · : A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans. · Regulato ...
-
RN Mgr/Head Nurse Domiciliary
hace 5 días
Veterans Affairs, Veterans Health Administration San Juan, Puerto RicoDetails Salary: Open · Categories: · General Nursing Internal Number: · The Domiciliary Nurse Manager (DNM) has substantial and continuous responsibility and accountability for the ongoing Quality Management and oversight in the Domiciliary. The incumbent will have direct o ...
-
Behavioral Health Advocate
hace 1 día
UnitedHealth Group San Juan, Puerto Rico De jornada completaOptum 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 ...
Clinical Reviewer - San Juan, Puerto Rico - UnitedHealth Group
Descripción
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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
Position in this function investigates Optum Waste and Error stopped claims by gathering information, researching state and federal guidelines, and following internal procedure to determine the viability of the claim for further review in a production environment.
Primary Responsibilities:
*** ENGLISH PROFICIENT ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***
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:
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.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
