Recovery Resolutions Analyst – RN or Coder – San Juan, PR – Remote

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 Recovery Resolutions Analyst RN/ Coder- is required to determine the accuracy of disputed claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date of service being reviewed. They must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and UHC/Client by following state and government compliance guidelines and the policies. They must confidently analyze and interpret data and medical records/documentation on a daily basis to understand historical claims activity, determine validity and demonstrate their ability to provide written or verbal communication to senior leadership on root cause identification.  You are responsible to investigate, review and provide clinical and/or coding expertise in a review of post-service, pre-payment or post-payment claims.

 

Interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make recommendation decisions based on findings.  It is important to be able to navigate through multiple claims applications (COSMOS, UNET, Facets, Pulse, etc.), to aid in research and work independently on making decisions on complex cases. 

 

If you are located in Puerto Rico, you will have the flexibility to work remotely* as you take on some tough challenges.

 

Primary Responsibilities: 

• Investigate, review and provide clinical and/or coding expertise in a review of post-service, pre-payment or post-payment claims
• Interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make recommendation decisions based on findings
• Provide coaching and education to reduce errors and improve client survey scores
• Identifies overt billing trends, waste and error identification, and recommends providers to be flagged or filtered for review
• Identifies updated clinical analytics opportunities and participates in projects necessary by client/other departments
• Ability to navigate through multiple claims applications (COSMOS, UNET, Facets, Pulse, etc.), to aid in research and work independently on making decisions on complex cases
• Maintains and manages daily case review assignments, with a high emphasis on quality, with at least 98% accuracy while following client/CMS guidelines
• Provides clinical explanation both to the provider and client in case management systems
• Participates in client/network meetings, which may include process changes and participates in additional projects as needed
• Assume additional responsibilities as assigned
• Analyze/research/understand how a claim was identified by Payment Integrity and determine appropriate resolution path
• Work with applicable business partners to obtain additional information relevant to the Payment Integrity case in order to drive resolution (e.g., Network Management, Claim Operations, OGS, UCHPI)
• Comprehend and adhere to applicable federal/state laws and regulations (e.g., DOI, ERISA, HIPAA, CMS)

 

***ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION***

 

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:

• Valid, active and unrestricted RN license or Certified Coder, such as AHIMA, AFAMEP, AAPC or Certification (CPC, CCS, CCA, RHIT, CPMA, RHIA or CDIP)
• 1+ years of experience working in a team atmosphere in a production driven environment with quality audit standards
• Proficiency with the Microsoft Office Suite (Word, PowerPoint, Excel – create/edit/save documents, and Outlook- email and calendar management)
• 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 (7:00am – 6:00pm). It may be necessary, given the business need, to work weekends and/or occasional overtime
• Professional proficiency in English
• You will be asked to perform this role in an office setting or other company location

 

Preferred Qualifications:

• Healthcare claims experience / processing experience
• Investigational and / or auditing experience, including government and state agency auditing
• Experience with Fraud Waste & Abuse or Payment Integrity
• Medical record review experience
• Knowledge of health insurance business, industry terminology, and regulatory guideline

 

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

 

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.