Optum is hiring: RN Clinical Reviewer (CPC Medical Coding Academy) - San Juan, P

RN Clinical Reviewer (CPC Medical Coding Academy) – San Juan, PR Optum is a global organization delivering care through technology. You will work in a role that investigates claims, gathers information, researches guidelines, and follows internal procedures to determine claim viability in a production environment. Primary Responsibilities Clinical Case Reviews – 75%: Perform clinical review of professional or facility claims against medical records to determine if the claim is supported; maintain productivity and accuracy standards defined by the department. Provide clear clinical logic to providers when necessary. Business operations oversight: Examine, assess, and document procedures to ensure data integrity, security, and process optimization; investigate, recover, and resolve all types of claims for health plans, commercial customers, and government entities; pursue recoveries; ensure adherence to state/federal compliance, reimbursement, and contract policies; use data and facts to solve problems. Other internal customer correspondence and team needs – 15%: Attend and provide feedback during monthly meetings with assigned internal customer department; offer continuous feedback to improve department relationships. Continuing education – 10%: Keep required coding certificate and/or nursing licensure active; complete compliance hours as required; English proficiency assessment required after application. Required Qualifications Registered Nurse (RN) with coding certificate or nursing licensure (e.g., Puerto Rico Registered Nurse, Certified Professional Coder (CPC) + CPC A, Certified Inpatient Coder (CIC), Certified Outpatient Auditor (COC), Certified Professional Medical Auditor (CPMA), Certified Coding Specialist (CCS)). Proficiency with computers, including Microsoft Suite. Availability to work Monday–Friday, 40 hours per week during business hours 8 am–7 pm ATL. Professional proficiency in both English and Spanish; English proficiency assessment required. Preferred Qualifications Experience in a hospital/inpatient setting, surgical or clinic. Experience with medical claims platforms. Experience coding evaluation and management services in outpatient/office setting. Presentation or policy documentation experience. Knowledge of CMS and AMA coding rules for CPT, HCPCS; CMS coverage, federal and state statutes, rules, and regulations; Medicaid/Medicare reimbursement methodologies; healthcare insurance/managed care industry; medical terminology and claim coding. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We are committed to fostering equity and inclusion in the workplace. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug‑free workplace. Candidates are required to pass a drug test before beginning employment. Seniority level: Entry level; Employment type: Full‑time; Job function: Health Care Provider; Industries: Claims Adjusting, Actuarial Services. #J-18808-Ljbffr