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Job Information

UnitedHealth Group Clinical Investigation Analyst - San Juan, PR in San Juan, Puerto Rico

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 which make UnitedHealth Group a Fortune 5 leader. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work. (sm)

As a Clinical Investigation Analyst , you will be responsible for helping to reduce medical costs by identifying waste and error in provider billing practices. As a Clinical Investigation Analyst , you will determine 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. You will exercise judgement / decision making on complex payment decisions that directly impact the provider and UnitedHealthcare / Client by following state and government compliance guidelines and the policies set forth by the department with a 98% accuracy rate. You will navigate all applicable claims applications (COSMOS, UNET, Facets, Pulse, etc.), and internal systems to research and work independently on making decisions on complex cases. You will 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:

  • Investigate, review, and provide 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

  • Identify 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

  • Identify updated clinical analytics opportunities and participates in projects necessary by client / other departments

  • Maintain and manage 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

  • Participate in provider / client / network meetings, which may include provider education through written communication and participates in additional projects as needed

  • Participate 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 – 6:00pm AST. It may be necessary, given the business need, to work occasional overtime or weekends. Our office is located in the Montehiedra area in San Juan.

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:

  • Currently possess a valid, active and unrestricted RN license

  • Intermediate Windows PC navigation proficiency or higher and ability to navigate in multiple systems

  • Knowledge of Microsoft Office including Word, PowerPoint, Excel, and Outlook (create/edit/save/send documents and emails)

  • Available to work (40 hours/week) Monday- Friday. Flexible to work any of our 8 hour shift schedules during our normal business hours of (7:00am to 6:00pm AST) It may be necessary, given the business need, to work occasional overtime or weekends.

  • English proficiency (Please note that an English proficiency assessment will be required for this position)

Preferred Qualifications:

  • Certified Coder, such as AHIMA or AAPC Certification (CPC, CCS, CCA, RHIT, CPMA, RHIA or CDIP)

  • Experience working in a team atmosphere in a production driven environment with quality audit standards

  • Investigational and / or auditing experience, including government and state agency auditing

  • NCLEX certification

  • Experience of UHC platforms - COSMOS, Facets and CPW and / or working with medical terminology or coding

  • Experience with Fraud, Waste & Abuse or Payment Integrity

  • Strong medical record review experience

  • Knowledge of health insurance business, industry terminology, and regulatory guidelines

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care 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: Clinical Nurses, Nurse, Medical Record Review, Coding Nurse, San Juan, PR, Puerto Rico