11 days old

Recovery Resolutions Analyst (Registered Nurse) - San Juan, PR

Blanding, UT 84511
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  • Job Code
    894158

The Recovery Resolutions Analyst RN -  is required to determine the accuracy of disputed claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date of service being reviewed. They must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and UHC/Client by following state and government compliance guidelines and the policies. They must confidently analyze and interpret data and medical records/documentation on a daily basis to understand historical claims activity, determine validity and demonstrate their ability to provide written or verbal communication to senior leadership on root cause identification.  You are responsible to investigate, review and provide clinical and/or coding expertise in a review of post-service, pre-payment or post-payment claims.

 

Interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make recommendation decisions based on findings.  It is important to be able to navigate through multiple claims applications (COSMOS, UNET, Facets, Pulse, etc.), to aid in research and work independently on making decisions on complex cases.  


Primary Responsibilities:
  • Investigate, review and provide clinical and/or coding expertise in a review of post-service, pre-payment or post-payment claims
  • Interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make recommendation decisions based on findings
  • Provide coaching and education to reduce errors and improve client survey scores
  • Identifies overt billing trends, waste and error identification, and recommends providers to be flagged or filtered for review
  • Identifies updated clinical analytics opportunities and participates in projects necessary by client/other departments
  • Ability to navigate through multiple claims applications (COSMOS, UNET, Facets, Pulse, etc.), to aid in research and work independently on making decisions on complex cases
  • Maintains and manages daily case review assignments, with a high emphasis on quality, with at least 98% accuracy while following client/CMS guidelines
  • Provides clinical explanation both to the provider and client in case management systems
  • Participates in client/network meetings, which may include process changes and participates in additional projects as needed
  • Assume additional responsibilities as assigned
  • Analyze/research/understand how a claim was identified by Payment Integrity and determine appropriate resolution path
  • Work with applicable business partners to obtain additional information relevant to the Payment Integrity case in order to drive resolution (e.g., Network Management, Claim Operations, OGS, UCHPI)
  • Comprehend and adhere to applicable federal/state laws and regulations (e.g., DOI, ERISA, HIPAA, CMS)

*** ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***

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.

 

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Posted: 2020-10-15 Expires: 2020-11-15

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Recovery Resolutions Analyst (Registered Nurse) - San Juan, PR

UnitedHealth Group
Blanding, UT 84511

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