IBR Clinical Appeals Analyst - Remote

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start **Caring. Connecting. Growing together.** The **Itemized Bill Review (IBR)** **Clinical Appeals Reviewer** will analyze and respond to client and/or hospital claim review appeal inquiries. Handles medical record review, analyzes data, and completes the response resolution for clients and the business unit. Must utilize expertise in auditing to review and provide response to appeals. We are seeking self\-motivated, solution\-oriented and skilled problem solver who provides clinical reviews with written documentation under tight deadlines. This position is full\-time, Monday \- Friday. Employees are required to work our normal business hours of 8:00am \- 5:00pm. It may be necessary, given the business need, to work occasional overtime or weekends. You'll enjoy the flexibility to work remotely \* from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** * Analyze scope and resolution of IBR Appeals * Respond to Level one, two or higher appeals * Perform complex conceptual analyses * Identifies risk factors, comorbidities', and adverse events, to determine if overpayment or claim adjustment is needed * Reviews governmental regulations and payer protocols and / or medical policy to recommend appropriate actions * Researches and prepares written appeals * Exercises clinical and/or coding judgment and experience * Collaborates with existing analysts, quality and leadership team to seek to understand, and review medical records pertaining to impacted claims * Navigates through web\-based portals and independently utilizes other online tools and resources including but not limited to word, adobe, excel * Serve as a key resource on complex and / or critical issues and help develop innovative solutions * Define and document / communicate business requirements 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:** * Undergraduate nursing degree * Unrestricted RN (registered nurse) license * 2\+ years of appeals experience (coding or auditing) * Experience with CPT\-4 coding, NCCI edit resolution and appropriate modifier use * Advanced experience with regulations, compliance and composing professional appeal responses * Advanced experience with ICD10 CM coding and ICD 10 PCS coding * Willing or ability to work our normal business hours of 8:00am \- 5:00p