Job Details
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The Senior Recovery/Resolution Analyst will work with a team to determine the accuracy of claims by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. They must be able to exercise critical decision making on complex cases by following state and government compliance guidelines, coding requirements and client policies.
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 (8:00am - 5:00pm). It may be necessary, given the business need, to work occasional overtime. This is a remote position.
Audits within the Payment Integrity Prepay Program involve determining whether coding on a claim submission is supported by medical record documentation and also checking if the codes are in accordance with industry coding standards as outlined by the Official Coding Guidelines, the applicable Coding Manual, and/or Coding Clinics. To this end, Payment Integrity Prepay Auditors are charged with rendering appropriate, well-supported, and thoroughly documented decisions which may result in the mitigation of improper payments (overpayments and underpayments) on claims on behalf of the client from various providers of clinical services including; Outpatient Facility Billing, Inpatient Facility Billing as well as other provider types and care settings. Payment Integrity Prepay Auditors need to effectively manage their caseload and monthly metrics in a production driven environment, ensuring they meet all compliance turnaround times mandated by the client, must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. They must have the ability to research, work independently, make decisions on complex cases, have strong written and verbal communication skills.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Clinical Case Reviews -75%
- Perform clinical review of facility claims vs. medical records to determine if the claim is supported or unsupported
- Maintain standards for productivity and accuracy. Standards are defined by the department
- Provide clear and concise clinical logic to the providers when necessary
- Maintains and manages daily case review assignments, with accountability to quality, utilization and productivity standards
- Other internal customer correspondence and team needs - 15%
- Attend and provide feedback during monthly meetings with assigned internal customer department
- Provide continuous feedback on how to improve the department relationships with internal team members and departments
- Engages in a collaborative work environment when applicable but is also able to work independently
- Continue education - 10%
- Keep up required Coding Certificate and/or Nursing Licensure
- Complete compliance hours as required by the department
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:
- Registered Nurse (RN) with an active, unrestricted RN License in the United States
- Active COC, CPC, or CCS Coding certification
- 2+ years of experience with claims auditing and researching claims information
- 1+ years of experience analyzing data and identify cost saving opportunities
- Experience working with medical claims platforms
- DRG Clinical Validation experience
- Knowledge of claims processing systems and guidelines/processes
- Intermediate skills with Microsoft Excel (create, edit, sort, filter, pivot tables) and Microsoft Word
Preferred Qualifications:
- Undergraduate’s degree (specify as either Associate’s or Bachelor’s Degree)
- CIC or CCS Certification (job responsibilities might evolve into needing these in the future)
- 1+ years of project management experience
- Knowledge of Medicaid/Medicare Reimbursement methodologies
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The hourly range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $33.75 to $66.25 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
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.
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.