Clinical Case Reviewer (Appeals Representative) RN or Coder - San Juan, PR

    • Hato Rey, PR

Position Description

Training classes start soon - apply today! Energize your career with one of Healthcare's fastest growing companies.

You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it's a dream that definitely can come true. Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.

This opportunity is with one of our most exciting business areas: Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 5 leader.

Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.

Already Fortune 6, we are totally focused on innovation and change. We work a little harder. We aim a little higher. We expect more from ourselves and each other. And at the end of the day, we're doing a lot of good.

The objective of the Clinical Case Review - RN or Certified Medical Coder is to help reduce the medical cost savings of United Health Group and their Government entities by identifying waste and error in provider billing practices. The Appeals Representative is responsible for determining the accuracy of the bill submitted by the provider to United Health group by comparing it to medical record submitted for the date of service being reviewed. They must be able to exercise judgement / decision making on complex payment decisions that directly impacts the provider and UHC / Client by following state and government compliance guidelines and the policies set forth by the department with 98 % accuracy. They must demonstrate an ability to maneuver through all applicable claims applications (COSMOS, UNET, Facets, Pulse, etc.), and over 19 internal applications to aid them in their research and work independently on making decisions on complex cases. They must confidently analyze and interpret data and medical records / documentation on a daily basis to understand historical claims activity, determine validity, and demonstrate their ability to provide written or verbal communication to senior leadership on root cause identification.

Primary Responsibilities:

  • Investigates, reviews, and provides clinical and / or coding expertise in review of post - service, pre - payment or post payment claims, which requires interpretation of state and federal mandates, billing practices / patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make pay / deny or payment recommendation decisions based on findings. This could include Medical Director / physician consultations and working independently while making their decisions
  • Identifies overt billing trends, waste and error identification, and recommends providers to be flagged or filtered for review and works with analytics on recommendations to increase line of business savings by client
  • Identifies updated clinical analytics opportunities and participates in projects necessary by client / other departments
  • Maintains and manages daily case review assignments, with a high emphasis on quality, with at least 98 % accuracy and within client / CMS guidelines and provides clinical explanation both to the provider
  • Participates in provider / client / network meetings, which may include provider education through written communication and participates in additional projects as needed
  • Participates in training of new staff and serves as a clinical resource to other areas within the clinical investigative team and provides guidance and feedback to peers when applicable

This position is full-time (40 hours/week) Monday- Friday. Employees are required to have flexibility to work any of our 8 hour shift schedules during our normal business hours of (7:00am - 7:00pm). It may be necessary, given the business need, to work weekends and/or occasional overtime.


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 / GED or higher
  • Currently possess one of the following credentials:
    • Certified Coder, such as AHIMA, AFAMEP, AAPC or Certification (CPC, CCS, CCA, RHIT, CPMA, RHIA or CDIP)
    • Valid, active and unrestricted RN license
  • Proficiency with the Microsoft Office Suite (Word, PowerPoint, Excel - create/edit/save documents, and Outlook- email and calendar management)
  • Professional proficiency in English

Preferred Qualifications:

  • CPT / HCPCS / ICD - 10 / CM / PCS coding experience
  • Experience working in a team atmosphere in a production driven environment with quality audit standards
  • Healthcare claims experience / processing experience
  • Investigational and / or auditing experience, including government and state agency auditing
  • Experience with Fraud Waste & Abuse or Payment Integrity
  • Medical record review experience
  • Knowledge of health insurance business, industry terminology, and regulatory guideline
  • Strong communication skills with the ability to interpret data

Helping create positive customer experiences for our members can drive your sense of impact and purpose. Join us as we improve the lives of millions. Learn more about how you can start doing your life's best work.(sm)

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

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.

Job Keywords: Appeals Rep, Clinical Case Reviewer, Claims, Optum, San Juan, Puerto Rico

Back to top