Senior Recovery Resolution Analyst

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 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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.  

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 8:00 AM – 5:00 PM. It may be necessary, given the business need, to work occasional overtime. 

We offer 4 weeks of on-the-job training. The hours of training will be aligned with your schedule.  

    

Primary Responsibilities:

• Responsible for auditing all cases with findings/ no findings prior to closure, provide feedback to individuals, review individual and peer historical performance. Provides coaching sessions as per the root cause analysis of identified errors
• 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 audit of 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 audit of 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
• Provides clinical support and expertise to the other investigative and analytical areas
• Participate 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.

Required Qualifications:

• High School Diploma / GED
• Certified Coder AHIMA or AAPC Certified coder (CPC, CCS, CCA, RHIT, CPMA, RHIA, CDIP)
• Must be 18 years of age OR older
• 2+ years of experience as AHIMA or AAPC Certified coder (CPT/HCPCS/ICD – 10/CM/PCS coding experience)
• 2+ years of practical experience interpreting reimbursement policies and provisions for Medicare, Community and State, and Employer and Individual
• Experience with Fraud Waste & Abuse or Payment Integrity
• Experience with Microsoft Word (create correspondence and work within templates), Microsoft Excel (data entry, sort / filter, and work within tables) and Microsoft Outlook (email and calendar management)
• Medical record review experience
• Understanding of Waste & Error principles
• Knowledge of Medicare reimbursement methodologies, i.e. Resource Based Relative Value System (RBRVS)
• Knowledge of health insurance business, industry terminology, and regulatory guidelines
• Ability to work full-time (40 hours/week), Monday – Friday. Employees are required to have flexibility to work on any of our 8-hour shift schedules during our normal business hours of 8:00 AM – 5:00 PM. It may be necessary, given the business need, to work occasional overtime.  

    

Preferred Qualifications:

• Nurse (RN, LPN) with unrestricted license
• 2+ years of auditing professional claims experience
• 2+ years of experience in Quality/Quality Management medical record review
• 1+ years of experience of UHC platforms – COSMOS, Facets, CIRRUS, UNET, ISET and CPW
• Investigational and/or auditing experience, including government and state agency auditing
• Experience in training, mentoring and/or development with adult learners
• Proficiency in Microsoft Excel (VLOOKUP’s, pivot tables, etc.), Microsoft OneNote (utilize and update information), Microsoft Teams
• Ability to assist with focusing activities on strategic direction and achieve targets demonstrated data management and/or project management skills  

    

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.

    

Soft Skills:

• Highly organized with effective and persuasive communication skills
• Strong written communication skills
• Open to change and new information; ability to adapt in changing environments and integrate best practices 
• Strong, analytical, problem-solving and decision-making skills; ability to exercise good judgment
• Time management and prioritization skills 
• Analytical problem-solving skills

    

Physical and Work Environment:

• Frequent speaking, listening using a headset, sitting, use of hands/fingers across keyboard  

    

*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 hourly pay for this role will range from $28.27 – $50.48 per hour 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.