Optum is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.If you get excited about the life transforming potential of bringing health care information to the right place, at the right time, to support crucial decisions, welcome to Optum. We're one of the largest and fastest growing health information companies and the only organization in our industry with the information, technology and consulting expertise to solve the most significant challenges in health and human services.
As a vital member of the UnitedHealth Group family, we serve customers in every segment of the health care field. This includes government agencies, Pharmaceutical Companies, Hospitals and health delivery networks, insurance providers and, of course, the diverse business divisions of UnitedHealth Group.
Bring your talent to an industry leader with the information, technology, and consulting expertise to help transform health and human services. No matter what your role, you'll be empowered to ask more questions, develop better solutions and help make the health care system greater than ever.
As a Recovery / Resolution Consultant - RN, you will be investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers and government entities. Role may include initiating telephone calls to members, providers and other insurance companies to gather medical records necessary to review the claim and coordination of benefits. Investigate and pursue recoveries and payables on subrogation claims and file management and processing recovery on claims. Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance. May conduct contestable investigations to review medical history. May monitor large claims including transplant cases
- Researching and interpreting healthcare claims payment policy to identify potential overpayment opportunities.
- Performing review of Provider documentation to identify overpayments related to fraud, waste, abuse, billing / coding errors and inappropriate utilization of services, as well as summarizing and documenting specifics of the review.
- Communicate all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations.
- Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance.
- Bachelor's degree or higher
- Current and unrestricted RN license in the state of residency
- 5+ years of experience as a RN, including experience in an inpatient / acute setting
- 1+ years of medical claims coding / processing / billing experience
- Demonstrated proficiency with Microsoft Word and Excel (Ability to create, edit, copy, send, and save documents, correspondence, and spreahsheets in MS Word and Excel)
- Demonstrated solid knowledge of medical billings including CPT, HCPC and ICD - 10
- A designated home work space with access to install secure high - speed internet via cable / DSL
- Previous managed care experience in utilization management or clinical claims review.
- Experience with using Milliman Care Guidelines (MCG) or Interqual.
- Certification in medical coding
- Experience working with algorithms
- Quality assurance experience
- Experience with MS Access
- Data analysis experience
- HIPAA experience
- Previous experience performing clinical reviews of medical records and supporting documentation from previous post - service determinations
- Investigative experience, experience talking with physicians or medical providers, reviewing medical claims, and resolving issues pertaining to medical claims and providers
Demonstrated excellent verbal and written communication skills
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health - related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity 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: Optum, Healthcare, Consultant, Recovery, Resolutions, Claims, Operations, Payment Integrity