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The 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.
Review suspect claim submissions to identify suspect or aberrant billing patterns.
Request Medical Records
Complete Comprehensive Investigative Reports
Conduct 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 Board
Collaborate with clinical, and / or legal on case strategies.
Identify new suspect providers
Identify opportunities to inactivate, or modify current flags, or edits
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.
We are committed to introducing innovative approaches, products and services that can improve personal health and promote healthier populations in local communities. Our core capabilities... in clinical care resources, information and technology uniquely enable us to meet the evolving needs of a changing health care environment as millions more Americans enter a structured system of health benefits and we help build a stronger, higher quality health system that is sustainable for the long term.
We serve our clients and consumers through two distinct platforms:
?UnitedHealthcare, which provides health care coverage and benefits services.
?Optum, which provides information and technology-enabled health services.