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  • Phoenix, AZ

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Recovery / Resolution Consultant - US Telecommute

UnitedHealth Group • Phoenix, AZ

Posted 11 days ago

Job Snapshot

Healthcare - Health Services
General Business, Health Care

Job Description

The health care system is still evolving at a rapid pace. Technology is driving new advances in how patient care is delivered and how it's reimbursed. Now, UnitedHealth Group invites you to help us build a more accurate and precise approach to claims adjudication. As part of our Recovery and Resolutions team, you'll provide consultative support to our business units and external vendor organizations. You'll handle requests, define business requirements and coordinate resolutions incorporating State / Federal regulations. Join us and build your career with an industry leader.

This is a challenging role with serious impact. You'll be assisting, educating, problem-solving and resolving challenging situations to the best possible outcomes. You'll need to understand and interpret clients' needs and ensure service and delivery excellence supporting the Fraud, Waste, Abuse, and Error product suite. This involves working with a high complexity solution set and cross functional teams to proactively review, research and resolve highly escalated inquiries.

Positions in this family support claim processing functions including investigations, negotiating settlements, payments, research regarding eligibility, etc. Positions in this function are responsible for investigating and resolving all types of claims. Make final claim payment determinations on claims. Ensure adherence to State and industry standard coding guidelines. Sr. Level Clinician / Coder serves as SME to Clinical Investigators. Assists in development in clinical review guidelines and provides mentoring / training on coding concepts.

Primary Responsibilities

  • Perform prepayment claims review analysis across multiple detection reasons which requires interpretation of medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims

  • Provide quality assurance reviews of medical records to confirm appropriate medical coding consistencies across review teams.

  • Ensure compliance with industry standard coding guidelines and State regulatory guidelines are created and updated to drive adherence to client SLAs.

  • Provide SME leadership/direction for clinical investigators  deliverables

  • Identify and develop efficiency opportunities which drives meeting and exceeding established productivity targets

  • Develop and present coding presentations and training to clinical investigators as necessary on various coding/clinical concepts

  • Develop and collaborate  in regular ongoing peer review of select inpatient, outpatient, and professional cases to ensure correct coding assignment

  • Develop appeals and reconsideration feedback integration into current processes.

  • Provide supplemental training to coding staff for new, existing, and modified analytics

  • Determine training and capability needs for pipeline analytics

  • Provide support as needed to Operations Policy Consultant in the development of clinical review guidelines

  • Document clinical determinations in prepayment review system

  • Reviews the work of others.

  • Develops innovative approaches.

  • Sought out as expert.

  • Serves as a leader / mentor.


  • BSN Nursing Degree or 2+ years RN with 7+ years clinical / coding experience

  • Possession of at least one (1) of the following valid certificates from the American Health Information Management Association (AHIMA): RHIT and/or CCS

  • 3+ Years DRG coding experience

  • 7+ years of CPT / HCPCS / ICD-9 / ICD-10 coding experience with a thorough knowledge of health insurance business, including knowledge of industry terminology and regulatory guidelines

  • 2+ years experience in leading clinical operations within a health plan / managed care environment OR 3+ years of client facing experience

  • 3+ Experience working with Encoder and abstracter software

UnitedHealth Group is a team of more than 260,000 people who are building career success through commitment, compassion and a desire to make a difference. Join us. Learn more about how you can start doing your life's best work.SM

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: clinical, investigator, senior, SME, coding, case review, recovery, resolution, consultant, operations, medical records, clinical review

Job ID: 2551_762165_1
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