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Pre-Record Review Investigator - Eden Prairie, MN
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Eden Prairie, MN Eden Prairie, Minnesota |
About this job
Position Description:
Energize
your career with one of Healthcare's fastest growing companies.
You
dream of a great career with a great company – where you can make an impact and
help people. We dream of giving you the
opportunity to do just this. And with
the incredible growth of our business, it's a dream that definitely can come
true. Already one of the world's leading Healthcare companies, UnitedHealth
Group is restlessly pursuing new ways to operate our service centers, improve
our service levels and help people lead healthier lives. We live for the opportunity to make a
difference and right now, we are living it up.
This
opportunity is with one of our most exciting business areas: Optum –a growing
part of our family of companies that make UnitedHealth Group a Fortune 17 leader.
Optum helps nearly 60
million Americans live their lives to the fullest by educating them about their
symptoms, conditions and treatments; helping them to navigate the system,
finance their healthcare needs and stay on track with their health goals. No
other business touches so many lives in such a positive way. And we do it all
with every action focused on our shared values of Integrity, Compassion,
Relationships, Innovation & Performance.
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 work.
The
Recovery/Resolution Analyst handles information about patient services
and how the services are paid by investigating and pursuing recoveries
through contact with various parties. The representative manages
subrogation files, negotiates settlements, and ensures adherence to
compliance policies.
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.
Primary Responsibilities:
- Investigate,
recover, and resolve all types of claims as well as recovery and
resolution for health plans, commercial customers, and government
entities - Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits
- 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
- Perform other duties as assigned
- 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
- Review Monthly Add/Delete Reports
- Liaison with customer for case specific inquiries
- The
Recovery/Resolution Analyst (Investigator) is responsible for the daily
assessment of suspect claims that edit to Optum for review. - Claims
and the requests for documentation to support or disprove an allegation
of abusive billing patterns must be handled within State and Department
of Insurance compliance time frames. - Meet required metrics and quality
- Analyzes and investigates.
- Provides explanations and interpretations within area of expertise.
Requirements
Requirements:
you will perform within an innovative culture that's focused on
transformational change in the Healthcare system. You will leverage your
skills across a diverse and multifaceted business. And you will make
contributions that will have an impact that's greater than you've ever
imagined.
Diversity creates a healthier atmosphere: All qualified
applicants will receive consideration for employment without regard to
race, color, religion, sex, age, national origin, protected veteran
status, disability status, sexual orientation, gender identity or
expression, marital status, genetic information, or any other
characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
- High School Diploma/GED
- Working Hours 7:30a-4:00p M-F with some flexibility
2+ years of work experience in the healthcare insurance industry
and/or health care claims processing or data entry experience- Beginner level of experience with Microsoft Excel (example: filter, format, save, edit)
- Experience working in a production environment
- Advanced knowledge and experience working on various approaches to health care fraud
- Medicare/Medicaid program knowledge a plus
- SIU work experience a plus
- Knowledge of the following Claims platforms: COSMOS; CPW; CSP; Diamond; Facets; NICE
- Frequent
speaking, listening using a headset, sitting, use of hands/fingers
across keyboard or mouse, handling other objects, long periods working
at a computer - Service center environment with moderate noise level due to Representatives talking, computers, printers, and floor activity
you will perform within an innovative culture that's focused on
transformational change in the Healthcare system. You will leverage your
skills across a diverse and multifaceted business. And you will make
contributions that will have an impact that's greater than you've ever
imagined.
Diversity creates a healthier atmosphere: All qualified
applicants will receive consideration for employment without regard to
race, color, religion, sex, age, national origin, protected veteran
status, disability status, sexual orientation, gender identity or
expression, marital status, genetic information, or any other
characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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