Recovery Resolution Consultant - Payment Integrity

UnitedHealth Group•Tampa, FL

8h•$72,800 - $130,000•Remote

About The Position

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 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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Recovery Resolution Consultant for Payment Integrity operations will serve as the operational expert for payment integrity programs. The recovery resolution consultant will aid in vendor implementations, vendor management and deliver daily operational functions. They will act as the subject matter expert for their function. Daily activities include verification of claims payment accuracy, providing state and federal policy expertise, data analysis, ensuring adherence to state and federal compliance policies, reimbursement policies and contract compliance, investigation and recovery of claims overpayments, and analytic rule validation and approval. The recovery resolution consultant will need to work with numerous matrix partners to manage deliverables, provide policy expertise, communicate change, and manage escalations. This position is full time, Monday - Friday. Employees are required to have flexibility to work any of our shift schedules during our normal business hours of 8:00 am - 4:30 pm EST. It may be necessary, given the business need, to work occasional overtime. This will be paid training. The hours of the training will be based on schedule or will be discussed on your first day of employment.

Requirements

High School Diploma / GED OR equivalent work experience
Must be 18 years of age OR older
3+ years of healthcare operations experience
3 + years of experience working within a health plan and / OR managed care business operations
3+ years of payment integrity experience: prepayment and / OR post-payment processes
Experience coordinating and navigating complex matrixed organizations
Data analysis and claims payment expertise
Track record of providing coaching and mentorship

Nice To Haves

Experience in aberrant billing detection, analytic methodologies, payment policies, and / OR provider contracts
Medical coding OR clinical experience and / OR certification (e.g., CPC, CCS, RHIA)
Vendor management experience
FACETS experience

Responsibilities

Functional process support for operations relating to the delivery of Payment Integrity
Provide claim process and reimbursement methodology expertise
Develop strong partnership with matrixed partners and stakeholders
Perform complex data analysis
Collaborate with a wide variety of matrix partners including but not limited to; network management, claims operations, compliance, regional and national medical directors, internal and external vendors, UHC, OGA
Coordinate with vendors to review and approve analytics that identify claims overpayments
Leverage claims processing system to research and validate overpayments
Coordinate with claims operations to submit claims overpayments and adjust in system & track to completion
Self-manage assigned tasks and deliverables to achieve set targets
Ensure that operational processes are standardized across multiple vendors and internal programs
Document and communicate outcomes of claims investigations/overpayment/prepayment reviews
Manage multiple line of business with varying regulations and compliance rules
Collaborate with claim operations and peer PI teams to identify ‘shift left’ opportunities
Manage and solve issues, escalations and complex problems applicable to assigned PI programs
Demonstrate understanding of applicable federal, state, and local compliance regulations (e.g., DOI, DOL, Healthcare Reform/PPACA, CMS) and ensure adherence
Manage, document, and prioritize workload in accordance with established targets
Achieve assigned operational targets; TAT, appeal, savings
Act as subject matter expert to identify quality improvement opportunities
Ideate and identify new opportunities for assigned programs