Recovery Resolution Consultant - Integrity

This position is National Remote. You'll enjoy the flexibility to telecommute
* from anywhere within the U.S. as you take on some tough challenges.

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 start Caring. Connecting. Growing together.

The Recovery Resolution Consultant for Payment Integrity operations will serve as the operational expert for payment integrity programs. The recovery resolution consultant will aid in vendor implementations, vendor management and deliver daily operational functions. They will act as the subject matter expert for their function. Daily activities include verification of claims payment accuracy, providing state and federal policy expertise, data analysis, ensuring adherence to state and federal compliance policies, reimbursement policies and contract compliance, investigation and recovery of claims over payments, and analytic rule validation and approval.

The recovery resolution consultant will need to work with numerous matrix partners to manage deliverables, provide policy expertise, communicate change, and manage escalations.

This position is full time, Monday - Friday. Employees are required to have flexibility to work any of our shift schedules during our normal business hours of 8:00 am - 4:30 pm EST. It may be necessary, given the business need, to work occasional overtime.

This will be paid training. The hours of the training will be based on schedule or will be discussed on your first day of employment.

• Functional process support for operations relating to the delivery of Payment Integrity
• Provide claim process and reimbursement methodology expertise
• Develop strong partnership with matrixed partners and stakeholders
• Perform complex data analysis
• Collaborate with a wide variety of matrix partners including but not limited to; network management, claims operations, compliance, regional and national medical directors, internal and external vendors, UHC, OGA
• Coordinate with vendors to review and approve analytics that identify claims over payments
• Leverage claims processing system to research and validate over payments
• Coordinate with claims operations to submit claims over payments and adjust in system & track to completion
• Self-manage assigned tasks and deliverables to achieve set targets
• Ensure that operational processes are standardized across multiple vendors and internal programs
• Document and communicate outcomes of claims investigations/over payment/prepayment reviews
• Manage multiple line of business with varying regulations and compliance rules
• Collaborate with claim operations and peer PI teams to identify 'shift left' opportunities
• Manage and solve issues, escalations and complex problems applicable to assigned PI programs
• Demonstrate understanding of applicable federal, state, and local compliance regulations (e.g., DOI, DOL, Healthcare Reform/PPACA, CMS) and ensure adherence
• Manage, document, and prioritize workload in accordance with established targets
• Achieve assigned operational targets; TAT, appeal, savings
• Act as subject matter expert to identify quality improvement opportunities
• Ideate and identify new opportunities for assigned programs

You'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.

• High School Diploma / GED OR equivalent work experience
• Must be 18 years of age OR older
• 3+ years of healthcare operations experience
• 3 + years of experience working within a health plan and / OR managed care business operations
• 3+ years of payment integrity experience: prepayment and / OR post-payment processes
• Experience coordinating and navigating complex matrixed organizations
• Data analysis and claims payment expertise
• Track record of providing coaching and mentorship

• Experience in aberrant billing detection, analytic methodologies, payment policies, and / OR provider…