Recovery Resolution Consultant
This position is national remote, offering the flexibility to telecommute from anywhere within the U.S.
About the Role
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, ultimately benefiting consumers. Our deep industry expertise and innovative technology empower organizations to reduce costs while improving risk management, quality, and revenue growth.
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, and contracts. The role also involves ideation to support new Data Mining opportunities and reviewing ad-hoc/standardized reporting to identify further savings. Collaboration with various matrix business partners is essential.
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 assess payment/overpayment issues/accuracy.
- Identify potential concepts for retrospective and prospective savings through individual ideation and from multiple perspectives (e.g., correct billing, clinical procedure coding, network contracting, policy reimbursement, medical documentation requirements, industry and federal guidelines).
- Enter information into applicable systems (e.g., Claim Miner, ODAR) to track processing of claims investigations and ensure all relevant claim information is documented.
- Document and communicate outcomes of claims investigations/overpayment reviews to applicable stakeholders.
Requirements
- High School Diploma / GED.
- Must be 18 years of age or older.
- 2+ years of healthcare 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, 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 to form cohesive and comprehensive recommendations or problem solutions.
- Proficiency in various claims payment methodologies, including 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.
Benefits
- Comprehensive benefits package.
- Incentive and recognition programs.
- Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
Pay
The salary for this role will range from $72,800 to $130,000 annually based on full-time employment.
Schedule
This position is full-time. Employees are required to have flexibility to work any of our shift schedules during normal business hours of 7:00 AM - 5:00 PM CST. It may be necessary, given business needs, to work occasional overtime. Training hours will be during normal business hours.