UnitedHealth Group

Title: RN – DRG Recovery / Resolution Consultant – US Telecommute

Location: Minneapolis Minnesota United States
Division:Optum Ops-Payment Integrity
Contest Number: 834434
Title: RN – DRG Recovery / Resolution Consultant – US Telecommute
Family: Claims
Function: Claim Recovery/Resol/COB/Subro
BusinessSegment: Optum Operations
Region: North America
Country: United States
City: Minneapolis
State: Minnesota
Other States: Texas Connecticut Arizona Florida
Other Cities: Dallas Hartford Phoenix Tampa
Employee Status:Regular
Job Level:Individual Contributor
Shift: Day Job
Travel: No
Overtime Status:Exempt
Telecommuter Position: Yes

Position Description

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 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 & 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 contractcompliance. May conduct contestable investigations to review medical history. May monitor large claims including transplant cases.

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.

Primary Responsibilities:

  • Research and interpret healthcare claims payment policy to identify potential overpayment opportunities
  • Perform review of Provider documentation to identify overpayments related to fraud, waste, abuse, billing / coding errors and inappropriate utilization of services, as well as summarize and document specifics of the review
  • Communicate all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations
  • Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance

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

Required Qualifications:

  • High School Diploma / GED 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 DRG coding 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 coding DRG,CPT, PCS, HCPC and ICD – 10
  • A designated home work space with access to install secure high – speed internet via cable / DSL
  • DRG Audit Experience
  • CCS or CPC certification

Preferred Qualifications:

  • Bachelor’s degree (or higher)
  • Experience with using Milliman Care Guidelines (MCG) or Interqual
  • Experience working with algorithms
  • Managed care experience in utilization management or clinical claims review
  • 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

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