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The Senior Recovery / Resolution Analyst will work with a team on researching issues to determine feasibility of reducing medical costs through prospective solutions of claim system processes and claim business rules.
Positions in this function are responsible for investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers and government entities. May include initiating telephone calls to members, providers and other insurance companies to gather coordination of benefits data. Investigate and pursue recoveries and payables on subrogation claims and file management. Process recovery on claims. Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance. May conduct contestable investigations to review medical history. May monitor large claims including transplant cases
Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance
Clinical and/or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. This could include Medical
Director / Physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
Performs clinical coverage review of post-service, pre - payment claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns
Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing
Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review
Maintains and manages daily case review assignments, with a high emphasis on quality
Provides clinical support and expertise to the other investigative and analytical areas
Participates in provider / client / network meetings, which may include provider education through written communication
Participates in training of new staff, and serves as a clinical resource to other areas within the clinical investigative team
Generally work is self-directed and not prescribed.
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.