Recovery Resolution Consultant - National Remote

Company: UnitedHealth Group
Location: Dallas
Posted on: May 3, 2025

Job Description:

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.This position is full time. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00am-4:00pm CST. It may be necessary, given the business need, to work occasional overtime.We offer on-the-job training. The hours of the training will be aligned with your schedule.You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.Primary Responsibilities:

• Investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical records review
• Serve as a Subject Matter Expert (SME), performing medical record reviews to include quality audits, as well as validation of accuracy and completeness of all coding elements, and medical necessity reviews.
• Responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development
• Serves cross-functionally with Medical Directors, and sometimes Utilization Management, as well as other internal teams to assist in identification of overpayments
• Serves as a SME for all Payment Integrity functions to include both Retrospective Data Mining, as well as Pre-Payment Cost Avoidance
• Identifies trends and patterns with overall program and individual provider coding practices
• Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable opportunityAre you up for navigating a complex matrix of business units and teams? We share a near obsessive desire to outperform and outdo our own achievements across our entire global business landscape. It's going to take all you've got to create valuable solutions to improve the health care system.You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.Required Qualifications:
  • Certified Professional Coder (CPC), or willingness to obtain within 6 months from hire date.
  • 5+ years of experience in the health insurance industry
  • 2+ years of experience with health insurance claims
  • 2+ years of experience with medical records review/auditing
  • 2+ years of using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc.
  • Experience interpreting provider contractual agreements
  • Experience with public speaking and presenting to large audiences, including Executives and Medical Directors
  • Experience with Fraud, Waste and Abuse programs and/or previous work within Payment Integrity
  • Proficiency in performing financial analysis/audit including statistical calculation and interpretation
  • Proficiency in various claims payment methodologies; to include capitation, fee-for-service, DRG, percent-of-charge, and OPPS
  • Proficiency using Microsoft Office: Word, Excel (data analysis, sorting/filtering, pivot tables), PowerPoint (prepare formal presentations and training), Visio (develop workflow processes)
  • Ability to work full time. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00am-4:00pm CST. It may be necessary, given the business need, to work occasional overtime.Preferred Qualifications:
    • Registered Nurse
    • 2+ years of Utilization Management
    • Experience working with federal contracts
    • Inpatient Coder with RHIT or RHIA
    • CES (Claims Editing System) SME, or SME in another clinical claims editing systemTelecommuting Requirements:
      • Ability to keep all company sensitive documents secure (if applicable)
      • Required to have a dedicated work area established that is separated from other living areas and provides information privacy
      • Must live in a location where there is a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy The salary range for this role is $71,600 to $140,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.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.UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.#RPO
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