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The Senior Recovery Resolution Analyst will Investigate Optum Waste and Error Claims Reviews to ensure accuracy of medical coding & billing.
This position is full-time (40 hours/week) 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 telecommute* from anywhere within the U.S. as you take on some tough challenges.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
- Performs clinical coverage review of CPT and HCPCS coded claims in a telecommuting work environment determining payment recommendation
- Determines appropriate level of service utilizing Evaluation and Management Coding principles
- Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
- Responsible for Clinical and Coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review.
- This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
- Performs clinical coverage review of post-service, pre-payment claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns
- Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing
- Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review
- Maintains and manages daily case review assignments, with accountability to quality and productivity standards
- Provides clinical support and expertise to the other investigative and analytical areas
- Participates in team and network meetings, engaging in a collaborative work environment
- Serves as a clinical resource to other areas within the clinical investigative team
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.
- High School Diploma /GED (or higher)
2+ years of current CPT and HCPCS coding experience (entering codes, auditing etc.)
Possess an unrestricted nursing license (RN/LVN/LPN) and/or are a current certified coder (CPC/CCS/RHIT etc.)
Experience with and ability to work independently with technology
Ability to work 8:00 am to 4:30 pm CST Monday through Friday and available to work overtime as business needs require
100% Attendance is required during Training
- Bachelor's Degree (or higher)
- Healthcare Claims experience
Managed Care experience
Investigational and/or Auditing experience
- Required to have a dedicated work area established that is separated from other living areas and provides information privacy
- Ability to keep all company sensitive documents secure (if applicable)
- Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
- Analytical problem solving skills
Physical Requirements and Work Environment:
- Frequent speaking, listening using a headset, sitting, use of hands/fingers across keyboard or mouse, handling other objects, long periods working at a comput
- Service center environment with moderate noise level due to Representatives talking, computers, printers, and floor activity
Careers with OptumInsight. Information and technology have amazing power to
transform the Healthcare industry and improve people's lives. This is where
it's happening. This is where you'll help solve the problems that have never
been solved. We're freeing information so it can be used safely and securely
wherever it's needed. We're creating the very best ideas that can most easily
be put into action to help our clients improve the quality of care and lower
costs for millions. This is where the best and the brightest work together to
make positive change a reality. This is the place 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.
Keywords: claims, data entry, coding, medical coding, customer service representative, customer service, CSR, UnitedHealth Group, Optum, OptumRx, call center, UnitedHealthcare, health care, healthcare, office, phone support, training class, advocate
CitizenshipStatus: Other Visa Accepted
Function: Claim Recovery/Resol/COB/Subro
Division: OI PI Clinical Ops
Shift: Day Job