Sr Recovery/Resolution Analyst
About The Position
Optum Insight is improving the flow of health data and information to create a more connected health system, helping care providers, payers, and consumers reduce friction and improve cost management, quality, risk management, and revenue growth. The Senior Recovery Resolution Analyst determines whether provider-submitted claims are accurate by comparing them with medical records for the dates of service under review. The role investigates and reviews post-payment claims, applying clinical and/or coding expertise and exercising judgment on complex payment decisions. Decisions must follow applicable state and federal requirements, coding rules, reimbursement policies, benefit language, and contract requirements. The analyst interprets claims data and medical documentation, reviews historical claims activity, assesses claim validity, and communicates findings to providers in writing. This is a production-driven, telecommuting role available from anywhere in the United States. The analyst manages daily case assignments and monthly metrics while meeting client-mandated compliance turnaround times. The role requires navigating multiple systems, researching complex cases independently, and collaborating with investigative, analytical, clinical, and business partner teams. UnitedHealth Group telecommuters must follow the company’s Telecommuter Policy.
Requirements
- High school diploma or GED.
- AHIMA- or AAPC-certified coder; accepted certifications include CPC, CCS, CCS-P, RHIT, CPMA, RHIA, or CDIP.
- At least 2 years of coding experience, including medical record auditing and coding/billing experience.
- At least 1 year of experience working in a team-based, metric-driven environment with daily production and quality standards.
- Intermediate medical record review experience.
- Intermediate experience with the health insurance business, industry terminology, and regulatory guidelines.
- Intermediate experience with Microsoft and Adobe applications, including Outlook, PowerPoint, Word, Excel, and PDF tools.
- Ability to navigate and maneuver multiple systems at once, with varying levels of complexity.
- Ability to review medical records and make decisions on complex cases independently.
- Frequent speaking, listening using a headset, sitting, and use of hands and fingers across a keyboard are required.
- Telecommuters must adhere to UnitedHealth Group’s Telecommuter Policy.
- Candidates must pass a drug test before beginning employment.
Nice To Haves
- Bachelor’s degree.
- Healthcare claims or claims processing experience.
- Strong communication skills and ability to interpret data.
- Experience with Fraud, Waste & Abuse or Payment Integrity.
- Experience with subsequent or reconsideration reviews for FWAE.
- Strong analytical mindset and experience working with medical terminology or coding.
- At least 1 year of experience with UHC platforms such as COSMOS, Facets, CPW, or NICE.
Responsibilities
- Perform quality audits of clinical review cases involving CPT, HCPCS, and modifiers assigned to claim codes.
- Determine the accuracy of medical coding and billing and make payment recommendations for post-payment claims.
- Conduct Medical Director or physician consultations as needed and interpret state and federal mandates, benefit language, medical and reimbursement policies, and relevant clinical information.
- Determine the appropriate level of service using Evaluation and Management coding principles.
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract requirements.
- Identify aberrant billing patterns and trends and evidence of fraud, waste, or abuse; recommend providers for review flagging.
- Maintain and manage daily case review assignments and meet quality, utilization, productivity, and turnaround-time standards.
- Provide clinical support and expertise to investigative and analytical areas and serve as a clinical resource to other areas of the clinical investigative team.
- Work with business partners to obtain additional information relevant to clinical reviews.
- Participate in team and department meetings and collaborate when appropriate while also working independently.
- Provide written communication to providers regarding review findings.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase program.
- 401(k) contribution, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
