Healthcare Claims Analyst - San Juan, PR

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.

Employees are responsible for triaging, investigating and resolving instances of healthcare fraud and/or abusive conduct by medical professionals. Using information from tips and complaints from plan members, the medical community and law enforcement, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. May conduct onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documents related to the investigation. Identify, communicate and recover losses as deemed appropriate. Where applicable, testimony regarding the investigation may be required. May also complete root cause analysis.

Primary Responsibilities:

• Assist the prospective team with special projects and reporting
• Initiate phone calls to members, providers, and other insurance companies to gather information
• Investigate and/or resolve all types of claims for health plans, commercial customers, and government entities
• Triage claims data to send for medical coding review
• Collaborate with clinical coding consultants for purposes of educating and communicating to provider
• Review medical records to gather relevant facts to drive investigations and communications
• Conduct data mining and analysis for potential flags
• Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders (referrals and OP)
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Utilize appropriate systems to monitor and document status of investigations
• Monitor investigation status throughout the process
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA
• Use pertinent data and facts to identify and solve a range of problems within area of expertise
• Generally, work is self - directed and not prescribed
• Work with less structured, more complex issues
• Serve as a resource to others

• 2+ years of experience in Claims processing
• Experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc.
• Working experience with Microsoft Tools: Microsoft Teams (join meetings and trainings), Microsoft Power Point (prepare presentations), Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports)
• Ability to work (40 hours/week) Monday - Friday. Flexible to work any of our 8-hour shift schedules during our normal business hours of (6:00am to 6:00pm EST). It may be necessary, given the business need, to occasionally work mandatory overtime, holidays or weekends
• English proficiency

• 1+ yrs of experience in Appeals and Grievances
• Experience with one or more of the following:
  
  
  • Provider demographic information
  • Insurance billing practices
• Organization affiliation and/or certification:
  • Association of Certified Fraud Examiners (ACFE)
    • Certified Fraud Examiner (CFE)
  • National Health Care Anti-Fraud Association (NHCAA)
    • Accredited Healthcare Fraud Investigator (AHFI)
  • International Association of Special Investigation Units (IASIU)
    • Certified Insurance Fraud Investigator (CIFI)
    • Certified Insurance Fraud Analyst (CIFA)
    • Certified Insurance Fraud Representative (CIFR)
• Coding experience
• Managed care experience
• Claims processing experience
• Medical record familiarity
• Experience in healthcare claims investigations
• Experience in lean and/or six sigma methodology