UnitedHealth Group is among the most ambitious Fortune 25 companies you'll ever meet. Through our family of businesses, we're working to make the health care system perform better for more people, in more ways than ever.
Simply put, we think the entire system can be greater than it's ever been. And that drives us to work harder, aim higher, and expect more from one another.
Here, you'll be empowered to make an immediate impact for millions of others. And you'll achieve more than you ever expected. How does that fit with your plans?
Clinical Investigations Manager - Eden Prairie, MN-313651
UnitedHealth Group is an innovative leader in the health and well-being industry, serving more than 55 million Americans. Through our family of companies, we contribute outstanding clinical insight with consumer-friendly services and advanced technology to help people achieve optimal health.
Description Ingenix is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
If you get excited about the life transforming potential of bringing health care information to the right place, at the right time, to support crucial decisions, welcome to Ingenix.
We're one of the largest and fastest growing health information companies and the only organization in our industry with the information, technology and consulting expertise to solve the most significant challenges in health and human services.
As a vital member of the UnitedHealth Group family, we serve customers in every segment of the health care field. This includes government agencies, pharmaceutical companies, hospitals and health delivery networks, insurance providers and, of course, the diverse business divisions of UnitedHealth Group.
Primary Responsibilities:
- Manages/leads the clinical investigations team that reviews prospective claims for aberrant billing patterns, within our fraud and abuse unit
- Manages/maintains the clinical review process assuring that medical policy and clinical standards for review of medical record documentation are followed
- Provides leadership necessary to support research and advancement of new aberrant treatment/billing patterns
- Collaborates with legal counsel, compliance managers, medical directors and other customers clinical staff to ensure applicable regulatory requirements are met, including referring suspect providers for reporting to various regulatory agencies
- Partners with the Quality Manager to ensure the highest quality standards are met. Initiates action plans to enhance the quality of the clinical/investigational case review
- Is a liaison with our global offshore partners to lead clinical subject matter expertise efforts, and resource balancing
- Leads operational and process improvements to support business goals
- Manages daily claim/case inventory and ensures turn around times are met
- Ensures clinical/operational performance standards and metrics are met
Bring your talent to an industry leader with the information, technology, and consulting expertise to help transform health and human services. No matter what your role, you'll be empowered to ask more questions, develop better solutions and help make the health care system greater than ever. Qualifications Qualifications:
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Registered nurse with active state license required
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3 years demonstrated experience in management/supervision of clinical staff in a healthcare insurance environment
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Extensive knowledge of claim coding and billing (including ICD-9, CPT, Revenue codes) with ability to identify aberrant treatment patterns and trends
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2 to 5 years experience in a clinical setting
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Extensive understanding of health care fraud & abuse investigations, with experience in utilization review
- Strong documentation skills with ability to articulate complex case findings to broad audience
- Strong leadership skills with ability to influence and establish credibility with internal/external contacts including physicians, practice managers, clients
- Exceptional collaborative, facilitation, communication and people motivational skills
- Experience in leading projects and/or process improvement initiatives
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Undergraduate degree or equivalent experience
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. All candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. |
