Zuleika Diaz Email and Phone Number

Clinical investigation analyst responsible for helping to reduce medicalcosts by identifying waste and errors in provider billing practices.Determine the accuracy of the bill submitted by the provider to UnitedHeath Group by comparing it to the medical record submitted for the dateof service being reviewed. Exercise judgment and decision-making oncomplex payment decisions that directly impact the provider andUnitedHealthcare / client by following state and government complianceguidelines and the policies set forth by the department with a 98%accuracy rate and within client/ CMS guidelines, while providing a clearand concise clinical explanation to the provider.Investigate, review, and provide clinical and coding expertise in thereview of prepayment claims, which require interpretation of state andfederal mandates, billing practices/patterns applicable benefit language,medical and reimbursement policies, coding requirements, andconsideration of relevant clinical information on claims with overt billingpatterns and make payment or denial recommendations based onfindings. Identify overt billing trends to increase line of business savingsby the client. Participate in the training of new staff and serve as a clinicalresource to other areas within the clinical investigative team by providingguidance and feedback to peers, and serving as backup Subject MatterExpert. Experience working in a team atmosphere in a production-drivenenvironment with quality audit standards. Investigation and auditingexperience with strong medical record review experience, knowledge ofhealth insurance business, industry terminology, and regulatorguidelines. Knowledge of relevant end-to-end claims adjudicationprocesses, strong medical record review experience, and healthcarecoding practices (CPT, HCPCS, ICD-10). Understanding of Medicare (CMS)policies and guidelines (LCD/NCD, NCCI, MPFS).

Ensure adherence to state and federal compliance policies,reimbursement policies, and contract compliance. Enter information intoapplicable systems to track the processing of claims investigations andensure that all information relevant to the claim is documented. Completefile setup, review claim information, and identify issues related topayment accuracy. Responsible for conducting research to identify errorsin claims processing, and updating applicable systems to ensure accuracy.Assist in the development and training of new hires by mentoringthrough work processes and performing internal quality assurance auditsof claims while providing feedback to reduce errors and improve processand performance. Apply payment integrity and Medicare experience,waste and error principles, inventory, and audit management. All tasksare performed independently in a telecommuter setting with minimalsupervision. Contribute to making changes to the job aid. Worked onescalated and priority cases as part of a task force team. Experienceworking in a team atmosphere in a production-driven environment withquality audit standards. Provide support across multiple healthcarebusiness segments such as cosmos processing, SIU, and C&S. Experiencewith UHC platforms – COSMOS, CPA, UNET, ORS, Facets, Tips Historical,DocDNA, Doc360, ECAA, and Picts.

Request, review, and analyze data of claim applications, physician'sstatements, medical records, vocational information to rate the degree ofdisability following the Program Operations Manual System and the Lawof the Social Security Administration Act to authorize payment of validclaims, or notify the claimant of denied claim and appeal rights. Compile,investigate, interpret, and analyze medical record evidence andvocational information of initial cases to determine eligibility fordisability benefits provided by the Social Security Act, to make adequateand precise determinations following the established rules and policiesthrough written and verbal requests via mail and telephone use, to publicand private clinics, hospitals, institutions, and independent medicalsources. Maintain a written record of all actions taken throughout theclaim process, redacting every document received in the official record.Authorize and complete request forms to acquire consultativeexaminations throughout all medical specialties such as psychiatric,psychological, ophthalmic, audiology, pulmonary, rheumatology,internist, and cardiology when additional evidence is needed to fullyassess the severity of medical conditions alleged by the claimant.Interview and correspond with claimants or attorneys/representatives toelicit information, correct errors or omissions on claim forms, andinvestigate questionable data. Authorize travel vouchers for and approvepayment of medical bills regarding the receipt of medical records.