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Job Details

UnitedHealth Group

Senior Recovery Resolution Specialist - Remote


Clinical Care Specialist/Staff Nurse


San Antonio, Texas, United States

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)

Positions in this family support claim processing functions including investigations, negotiating settlements, payments, research regarding eligibility, etc.

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.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

General Job Profile:

  • Extensive work experience, possibly in multiple functions
  • Work does not usually require established procedures
  • Works independently
  • Mentors others
  • Acts as a resource for others. Coordinates others' activities

Primary Responsibilities:

  • Applies knowledge/skills to complex activities
  • Demonstrates a depth and breadth of knowledge/skills in own area and is often able to apply these outside of own function. Often acts as a technical resource to others in own function
  • Anticipates customer needs and proactively identifies solutions
  • Solves complex problems on own; proactively identifies new solutions to problems
  • Plans, prioritizes, organizes and completes work to meet established objectives
  • Acts as a facilitator to resolve conflicts on team; seen as key team member on project teams spanning more than own function

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.

Required Qualifications:

  • High school education or equivalent experience

Functional Competency & Description

  • Ensure Claims Payment Accuracy
    • Obtain all available data relevant to investigation/overpayment identifications
    • Conduct/utilize investigations/overpayment identifications to determine accuracy of claims payments (prospectively and retrospectively)
    • Analyze contractual requirements to determine if funds are owed to payers
    • Perform research/verification of identified claims to identify payment/overpayment issues/accuracy
    • Enter information into applicable systems to track processing of claims investigations and/or to ensure that all information relevant to the claim is documented (e.g., SubroTrack, SubroNow, WOW, ODAR, ORS)
    • Complete file set up on subrogation/workers' compensation cases
    • Work with payers/providers to review claim information and identify issues related to payment accuracy
    • Update applicable claims systems to ensure that claims payments reflect accurate payment levels and appropriate payers (COB, primary vs. secondary payers)
    • Document and communicate outcomes of claims investigations/overpayment reviews to applicable stakeholders
  • Ensure Recovery of Claims Payments
    • Work with internal and/or external stakeholders (e.g., providers, provider advocates, Network Management) to facilitate resolution of overpayments
    • Negotiate recovery amounts with applicable stakeholders (e.g., attorneys, other insurance carriers, members, providers)
    • Communicate overpayment information to payers/providers as appropriate, including explanations of the reasons for overpayment (e.g., inbound/outbound calls, letters, emails)
    • Support audits of payment checks (e.g., commercial client recoveries)
    • Disburse clients' net checks
    • Manage conversations with stakeholders to ensure clear understanding and that accurate information is obtained
    • Verify/validate applicable systems to reflect updated COB information and ensure that future payments are processed correctly
    • Drive resolution of overpayments based on relevant claims information, policies, and regulations
    • Address concerns/inquiries/appeals from providers (e.g., obtain commitment of provider/other entity to refund, close overpayment, obtain check or offset)
    • Review recommendations resulting from investigations to ensure accuracy and consistency with internal and/or external policies and procedures
    • Verify/ensure that overpayment/refund checks are properly applied to the appropriate claims/overpayments
  • Develop/Manage/Maintain Internal and External Relationships
  • Develop and maintain relationships with applicable internal stakeholders (e.g., Claims Operations, Network Provider Relations, internal business segments)
  • Develop and maintain relationships with applicable external stakeholders (e.g., members, providers, commercial clients, government/regulatory agencies, vendors)
  • Identify and address problems/issues that exist or emerge in stakeholder relationships
  • Ensure Achievement of Applicable Performance Targets/Metrics
    • Manage, document and prioritize case load individual and department (e.g., TAT, schedule adherence)
    • Achieve applicable targets/metrics (e.g., recovery targets, production targets, financial targets, settlement ratios, quality targets) Report and monitor overpayment identifications and resolutions in order to establish and measure progress against targets and objectives
    • Review applicable scorecards (e.g., daily, monthly) and identify/address issues that may impact achievement of performance targets/metrics
    • Identify, implement, and report opportunities to improve processes, procedures, systems, and/or organizational structures (e.g., to drive improved quality/ efficiency, strengthen stakeholder relationships)
  • Demonstrate Knowledge of Internal and External Policies, Laws and Regulations
    • Demonstrate understanding of applicable federal, state, and local compliance regulations (e.g., DOI, DOL, Healthcare Reform/PPACA, CMS)
    • Demonstrate understanding of contractual compliance regulations (e.g., providerspecific contracts, statespecific COCs, customerspecific contracts)
    • Demonstrate understanding of relevant privacy regulations (e.g., HIPAA, ERISA, fair claims practices/laws)
    • Demonstrate understanding of internal processes and procedures (e.g., claims processing, subrogation processes, primacy determination, workers' compensation)
    • Demonstrate understanding of applicable policies, procedures, and regulations across the enterprise (e.g., Medicare and Retirement, Community and State, Commercial, Behavioral Health)
    • Maintain awareness of new or emerging policies, laws and regulations, as needed
    • Create/contribute to development of new/enhanced internal policies, procedures (e.g., process flow documents)
  • Demonstrate Knowledge of Applicable Systems and Processes
    • Utilize applicable tools/resources to investigate and document claims payments/overpayments (e.g., SubroTrack, SubroNow,
    • WOW, ODAR)
    • Demonstrate knowledge of healthcare coding practices (e.g., CPT's, HCPCS, DRG, ICD9, ICD10)
    • Demonstrate understanding of how to read and interpret medical records
    • Demonstrate understanding of relevant endtoend claims adjudication processes
    • Demonstrate understanding of applicable claims platforms (e.g., UNET, COSMOS, Diamond, FACETS, Unison, NICE, Pulse)
    • Demonstrate understanding of processes and systems across multiple healthcare business segments (e.g., Medicare and Retirement, Community and State (Medicaid), Commercial, Behavioral Health)

Values Based Competencies
1. Integrity Value: Act Ethically

  • Comply with Applicable Laws, Regulations and Policies
  • Demonstrate Integrity

2. Compassion Value: Focus on Customers

  • Identify and Exceed Customer Expectations
  • Improve the Customer Experience

3. Relationships Value: Act as a Team Player

  • Collaborate with Others
  • Demonstrate Diversity Awareness
  • Learn and Develop

4. Relationships Value: Communicate Effectively

  • Influence Others
  • Listen Actively
  • Speak and Write Clearly
  • 5. Innovation Value: Support Change and Innovation
  • Contribute Innovative Ideas
  • Work Effectively in a Changing Environment

6. Performance Value: Make FactBased Decisions

  • Apply Business Knowledge
  • Use Sound Judgement

7. Performance Value: Deliver Quality Results

  • Drive for Results
  • Manage Time Effectively
  • Produce HighQuality Work

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID19 vaccination regulations as well as all client COVID19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multispecialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

WellMed was founded in 1990 with a vision of being a physicianled company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.

Colorado, Connecticut, Nevada, or New York City Residents Only: The hourly range for Colorado residents is $18.17 to $32.26. The hourly range for Connecticut/Nevada/New York City residents is $20.00 to $35.53. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a farreaching choice of benefits and incentives.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and 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.

OptumCare is a drugfree workplace. Candidates are required to pass a drug test before beginning employment.