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This role performs audit process activities related to Audit and Recovery programs. The incumbent will review production audits including but not limited to, contracts, fee schedules, coordination of benefits, client specific systems, procedural documentation associated with the assigned work. The incumbent will review ad hoc audits, client referrals and test new audits in development. The objective is to identify identifying claim overpayments from claims paid data, identify changes in data and audits and make recommendations for solutions and improved results.
- Demonstrating proficiency on assigned audits
- Handle ad hoc audits and referrals associated systems and policies.
- Perform complex claims analysis, identify trends and root causes of payment inaccuracies
- Production and quality metrics along with defined turnaround times are achieved on an ongoing basis
- Ensure all audit results are supported by documentation, contract, state and client compliance is followed
- Audit findings are documented and submitted according to standard practices for the client
- Auditors are expected to understand all payment methodologies / claim benefits and be able to calculate overpayments that will be communicated to a provider
- Maintain any databases and spreadsheets related to assigned work
- Communicating to their manager any issues impeding progress of goals and suggesting solutions to meet and exceed expectations
- Work collaboratively with all internal and external parties
- Monitor and manage all aspects of assigned responsibilities by organizing, planning and tracking assigned tasks and priorities to ensure financial and client service level commitments are exceeded
- Research relevant systems and documentation and solve for open issues such as contract documentation and discrepancies
- Support the overall team objectives
- A responsibility of this role is to continually look for new opportunities in data they are reviewing and to seek and suggest process improvements
- High School Diploma / GED or Higher
- 2+ years health plan and / or claim, financial analysis, or related experience
- Ability to analyze large sets of data to identify mispaid claims, and identify trends / root causes
- Ability to create, edit, copy, send and save documents, correspondence, and spreadsheets in MS Word and Excel.
- Working knowledge of claim payment methodologies and reimbursement industry protocol
- Bachelor’s degree or higher preferred
- 1+ years of UNET Claims platform experience
- In - depth knowledge of managed care and government operations / products preferred
- Certification of Medical coding or 5+ years of extensive coding experience preferred
- Ability to make audit decisions using multiple inputs
- Ability to interpret multiple payment processes, methodologies and policies
- Familiarity with 3 - 5 claim platforms or similar operating system technology
- Ability to make decisions and work independently in a fast - paced environment
- Excellent written and verbal communication skills
- Excellent collaboration skills
- Ability to manage multiple priorities
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, COSMOS, Claims, Telephonic, Recovery, Resolution