Position Description:Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best workThe Recovery / Resolution Analyst (Investigator) performs the investigative function, to include daily assessment of claims that pend to OptumInsight to determine if they warrant further review, member / provider interviews, license verification, and overall case oversight to ensure prompt pay time frames are met. They collaborate with the Clinical Investigator, Legal, and Compliance, for case strategies. Perform low level Provider Education, identify new suspect providers, assess current flags and edits, and when appropriate refer to the Government Case Affair team for reporting to the appropriate Department of Insurance or Medical Board. Investigators also serve as a point of contact for customers regarding case specific inquiries. Primary Responsibilities:Review suspect claim submissions to identify suspect or aberrant billing patterns.Request Medical RecordsComplete Comprehensive Investigative ReportsConduct provider license checks utilizing various investigative sources.Communicate and identify new aberrant claim activity to other related departments.Conduct member / provider telephonic interviews. Submit suspect providers for reporting, to the Department of Insurance or appropriate Medical BoardCollaborate with clinical, and / or legal on case strategies.Identify new suspect providersIdentify opportunities to inactivate, or modify current flags, or editsReview Monthly Add / Delete ReportsLiaison with customer for case specific inquiries
Requirements:High School Diploma / GED or higher Experience using Excel creating and maintaining spreadsheets1+ years experience working in an office setting environment in the healthcare insurance industry Assets:2+ years experience with healthcare claims processing or data entryAdvanced knowledge and experience working on various approaches to health care fraudExperience working in a production environmentMedicare / Medicaid program knowledge a plusSIU work experience a plusKnowledge of the following Claims platforms: COSMOS; CPW; CSP; Diamond; Facets; NICEPhysical Requirements and Work Environment:Frequent speaking, listening using a headset, sitting, use of hands/fingers across keyboard or mouse, handling other objects, long periods working at a computerService center environment with moderate noise level due to Representatives talking, computers, printers, and floor activityCareers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work. Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.Key words: claims, medical claims, healthcare claims, claims processing, claims processor; office, UnitedHealth Group, Optum, training class, customer service representative, customer service, CSR, Data Entry, adjustments, phone support
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.