Clinical Resolution Specialist

hace 3 días

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

Optum is a global organization delivering care, supported by technology to help millions of people live healthier lives.

The Clinical Resolution Specialist will determine the accuracy of disputed claims submitted by providers by comparing them to medical records. They must analyze data and make informed decisions based on state and government compliance guidelines.

This role requires strong analytical skills to review medical records and interpret data to understand historical claims activity. The specialist will also communicate complex information to senior leadership and provide written or verbal explanations.

The primary responsibilities include investigating, reviewing, and providing clinical expertise in claim reviews. This involves interpreting state and federal mandates, billing practices, and applicable benefit language.

Key Responsibilities:

  • Investigate and review claims to determine accuracy
  • Analyze data to understand historical claims activity
  • Provide written or verbal explanations for complex information
  • Communicate with senior leadership to resolve issues
  • Interpret state and federal mandates, billing practices, and applicable benefit language

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