Clinical Resolution Specialist

hace 1 día

San Juan, San Juan, Puerto Rico Optum A tiempo completo

About Optum

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Optum, a global healthcare organization, delivers care and technology to help millions of people live healthier lives. Our team is dedicated to improving health outcomes by connecting individuals with the care, pharmacy benefits, data, and resources they need to feel their best.

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The Role of a Recovery Resolutions Analyst RN/Coder

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A key member of our team will be responsible for determining the accuracy of disputed claims submitted by healthcare providers. This involves comparing the submitted claims to medical records and exercising judgment in making complex payment decisions that directly impact both the provider and UnitedHealth Group/Client.

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Key Responsibilities

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  • Investigate and review post-service, pre-payment or post-payment claims">
  • Analyze and interpret data and medical records/documentation to determine validity">
  • Provide written or verbal communication to senior leadership on root cause identification">
  • Work independently to research and make decisions on complex cases">
  • Navigate through multiple claims applications to aid in research">
  • Maintain daily case review assignments with high emphasis on quality (at least 98% accuracy)">
  • Participate in client/network meetings and assume additional responsibilities as assigned">
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Requirements and Qualifications

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To succeed in this role, you must possess a valid, active and unrestricted RN license or certified coder credentials. Additionally, you should have at least one year of experience working in a production-driven environment with quality audit standards.

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Benefits and Opportunities

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This full-time position offers flexibility in working hours and comes with comprehensive benefits and opportunities for career growth and development.

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