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  • Tampa, FL

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RN - Recovery / Resolution Consultant - US Telecommute

UnitedHealth Group • Tampa, FL

Posted 1 month ago

Job Snapshot

Full-Time
Healthcare - Health Services
General Business, Health Care

Job Description

Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.


This opportunity is with one of our most exciting business areas: Optum – a growing part of our family of companies that make UnitedHealth Group a Fortune 5 leader.

Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation and Performance.

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.

As a RN - Recovery / Resolution Consultant, 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.

Candidate must have DRG Coding and Audit Experience to be considered for this role.

Primary Responsibilities:

  • 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
  • Communicating all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations
  • Ensuring adherence to state and federal compliance policies, reimbursement policies and contract compliance

Required Qualifications:
  • 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
  • Proficiency with Microsoft Word and Microsoft Excel (Ability to create, edit, copy, send, and save documents, correspondence, and spreadsheets)
  • 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
  • Managed care experience in utilization management or clinical claims review
  • Experience with using Milliman Care Guidelines (MCG) or Interqual
  • DRG Coding / Audit Experience
Preferred Qualifications:
  • Certification in medical coding
  • Experience working with algorithms
  • Quality assurance experience
  • Experience with Microsoft Access (ability to run queries, create macros etc.)
  • Data analysis experience
  • HIPAA experience
  • 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
Soft Skills:
  •     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
Job ID: 2551_822924_3
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