Recovery Resolution Consultant

This position is National Remote. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. This role performs auditing activities related to Data Mining programs. The successful candidate will review all types of medical claim payments against, COB/Data Mining workflow inventory, claims platforms, contracts etc. This role also involves ideation in support of new Data Mining opportunities and reviewing ad-hoc/standardized reporting with a view to identifying further savings. The successful candidate should have prior experience within the U.S. HealthCare industry with specific proficiency within reimbursement policy, provider contracts and clinical coding. Prior experience within Payment Integrity, Network Management or Claims Operations is a distinct advantage. All the above is undertaken in collaboration with various matrix business partners. General Profile: Production Oriented, Identification and validation of overpayments New concept ideation Excellent relationship management Industry Knowledge This position is full-time. Employees are required to have flexibility to work any of our shift schedules during our normal business hours of 7am - 5pm CST. It may be necessary, given the business need, to work occasional overtime. This will be on the job training and the hours during training will be during normal business hours.

Obtain all available data relevant to investigation/overpayment identifications Conduct/utilize audit investigations/overpayment identifications to determine accuracy of claims payments (prospectively and retrospectively) Analyze contractual requirements to determine if funds are owed to payers Perform research/verification of identified claims to identify payment/overpayment issues/accuracy Identify potential concepts for retrospective and prospective savings through individual ideation and from several perspectives such as correct billing, clinical procedure coding, network contracting, policy reimbursement, medical documentation requirements, industry and federal guidelines Enter information into applicable systems to track processing of claims investigations and/or to ensure that all information relevant to the claim is documented (e.g., Claim Miner, ODAR) Document and communicate outcomes of claims investigations/overpayment reviews to applicable stakeholders You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

High School Diploma / GED Must be 18 years of age OR older 2+ years of health care experience working with claims data and / or medical codes 2+ years of experience with medical claims auditing and researching medical claims 1+ years of experience working with processing and reviewing medical claims platforms information including review of medical records Experience analyzing large data sets to determine trends / patterns Experience reading and interpreting medical records, provider contracts, fee schedules, and claim payment policies Intermediate experience in Microsoft Office programs Ability to gather and analyze information from multiple sources and use to form a cohesive and comprehensive recommendation or problem solution Proficiency in various claims payment