RN - Recovery / Resolution Consultant

UnitedHealth Group - Tampa, FL3.6

Energize your career with one of Healthcare’s fastest growing companies.

You dream of a great career with a great company – where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it’s a dream that definitely can come true. Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.

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 6 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 & 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.

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 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

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
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.
DRG Coding / Audit Experience

Preferred Qualifications:
Certification in medical coding
Experience working with algorithms
Quality assurance experience
Experience with MS Access (ability to run queries, create macros etc.)
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

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.