Recovery Resolution Consultant

This position is National Remote. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

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.

This role performs auditing activities related to Data Mining programs. The successful candidate will review all types of medical claim payments against, COB/Data Mining workflow inventory, claims platforms, contracts etc. This role also involves ideation in support of new Data Mining opportunities and reviewing ad-hoc/standardized reporting with a view to identifying further savings. The successful candidate should have prior experience within the U.S. HealthCare industry with specific proficiency within reimbursement policy, provider contracts and clinical coding. Prior experience within Payment Integrity, Network Management or Claims Operations is a distinct advantage. All the above is undertaken in collaboration with various matrix business partners. 

General Profile:   

• Production Oriented, Identification and validation of overpayments  
• New concept ideation 
• Excellent relationship management   
• Industry Knowledge  

This position is full-time. Employees are required to have flexibility to work any of our shift schedules during our normal business hours of 7am - 5pm CST. It may be necessary, given the business need, to work occasional overtime. 

This will be on the job training and the hours during training will be during normal business hours.  

   

Primary Responsibilities:

• Obtain all available data relevant to investigation/overpayment identifications 
• Conduct/utilize audit investigations/overpayment identifications to determine accuracy of claims payments (prospectively and retrospectively) 
• Analyze contractual requirements to determine if funds are owed to payers 
• Perform research/verification of identified claims to identify payment/overpayment issues/accuracy 
• Identify potential concepts for retrospective and prospective savings through individual ideation and from several perspectives such as correct billing, clinical procedure coding, network contracting, policy reimbursement, medical documentation requirements, industry and federal guidelines  
• Enter information into applicable systems to track processing of claims investigations and/or to ensure that all information relevant to the claim is documented (e.g., Claim Miner, ODAR) 
• Document and communicate outcomes of claims investigations/overpayment reviews to applicable stakeholders  

   

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: 

• High School Diploma / GED 
• Must be 18 years of age OR older
• 2+ years of health care experience working with claims data and / or medical codes
• 2+ years of experience with medical claims auditing and researching medical claims  
• 1+ years of experience working with processing and reviewing medical claims platforms information including review of medical records 
• Experience analyzing large data sets to determine trends / patterns 
• Experience reading and interpreting medical records, provider contracts, fee schedules, and claim payment policies 
• Intermediate experience in Microsoft Office programs
• Ability to gather and analyze information from multiple sources and use to form a cohesive and comprehensive recommendation or problem solution
• Proficiency in various claims payment methodologies; to include capitation, fee-for-service, DRG, percent-of-charge, CMS OPPS, etc. 
• Ability to work shifts between 7:00 AM and 5:00 PM CST, with flexibility based on business needs

   

Preferred Qualifications: 

• Experience with Pharmacy and Home Health audits

   

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

   

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

   

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. 

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 

   

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

   

   

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.

Job Details
Job: Claim Recovery/Resol/COB/Subro
Primary Location: US-TX-Dallas
Other Locations: US-CT-Hartford, US-MN-Minneapolis, US-AZ-Phoenix, US-FL-Tampa
Organization: PI Non-Clinical Ops
Schedule: Full-time