Senior Recovery Resolution Analyst - Inpatient Review

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best.Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale.Join us to startCaring. Connecting. Growing together.Audits within the Payment Integrity Prepay Program involve determining whether coding on a claim submission is supported by medical record documentation. They also check if the codes are in accordance with industry coding standards as outlined by the Official Coding Guidelines, the applicable ICD Coding Manual, and/or Coding Clinics. To this end, Payment Integrity Prepay Auditors are charged with rendering appropriate, well-supported, and thoroughly-documented decisions which may result in the identification of improper payments (overpayments and underpayments) on paid claims on behalf of the client from various providers of clinical services, including but not limited to acute care, long-term acute care, acute rehabilitation, and skilled nursing facilities, as well as other provider types and care settings.You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.Primary Responsibilities:Clinical Case Reviews -75%Perform clinical review of facility claims vs. medical records to determine if the claim is supported or unsupportedMaintain standards for productivity and accuracy. Standards are defined by the departmentPerforms Billing and Coding Validations, to include but not limited to, MS-DRG/APR-DRG validation, Prospective Payment Systems (HIPPS), CVA, APC, etc.Provide clear and concise clinical logic to the providers when necessaryExamine, assess, and document business operations and procedures to ensure data integrity, data security and process optimizationInvestigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entitiesInvestigate and pursue recoveriesEnsure adherence to state and federal compliance policies, reimbursement policies, and contract complianceMaintains strict patient and physician confidentiality and follows all federal, state and hospital guidelines for release of information Use pertinent data and facts to identify and solve a range of problems within the area of expertiseVerify the following elements in the medical recordAccuracy of the procedure code assignment(s)Accuracy of the sequencing of codesPatient Accuracy and Provider informationOther internal customer correspondence and team needs – 15%Attend and provide feedback during monthly meetings with assigned internal customer departmentProvide continuous feedback on how to improve the department relationships with internal team members and departmentsContinue education – 10%Keep up required Coding Certificate and/or Nursing LicensureComplete compliance hours as required by the departmentYou’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.Required Qualifications:High School Diploma/GED(or higher)Active RN license in state of residenceProfessional active CCS or CIC coder certification1+ years of experience with claims auditing and researching claims information in a facility/hospital setting1+ years of MS DRG/APR DRG/CVA coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies1+ years of experience working with CMS and AMA coding rules specific to ICD-10-PCS, CPT, HCPCSPreferred Qualifications:Previous experience working in a production-based environmentComprehensive understanding of hospital coding and billing techniques and revenue cyclesStrong customer service skillsAbility to work in a teamProficient with personal computers, including Microsoft Suite of productsStrong analytical and problem-solving skillsExperience working in a production-based environment measured by monthly business objectivesDRG Coding ExperienceMedicaid and/or Medicare experiencePrevious presentation or policy documentation experienceSoft Skills:Strong written and verbal communications skillsAbility to work in a teamStrong analytical and problem-solving skills skills*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable.Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.Application Deadline:This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.UnitedHealth Groupis a drug - free workplace. Candidates are required to pass a drug test before beginning employment.#RPO #GREEN #J-18808-Ljbffr

Created: 2025-10-08