UnitedHealth Group
RN - DRG Recovery / Resolution Consultant - US Telecommute
At a glance
Location: US-MN-Minneapolis Map
Posted: 08/01/2019
Closing: 08/31/2019
Degree: Not Specified
Type: Full-Time
Experience: Not Specified
UnitedHealth Group
Job description

Energize your career with one of Healthcare’s fastest growing companies.  

You dream of a great career with a great company – where you can make an impact and help people.  We dream of giving you the opportunity to do just this.  And with the incredible growth of our business, it’s a dream that definitely can come true. Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives.  We live for the opportunity to make a difference and right now, we are living it up.

This opportunity is with one of our most exciting business areas: Optum – a growing part of our family of companies that make UnitedHealth Group a Fortune 5 leader.


Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.

As a vital member of the UnitedHealth Group family, we serve customers in every segment of the health care field. This includes government agencies, Pharmaceutical Companies, Hospitals and health delivery networks, insurance providers and, of course, the diverse business divisions of UnitedHealth Group.

As a RN - Recovery / Resolution Consultant, you will be investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers and government entities.  Role may include initiating telephone calls to members, providers and other insurance companies to gather medical records necessary to review the claim and coordination of benefits.  Investigate and pursue recoveries and payables on subrogation claims and file management and processing 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.


UnitedHealth Group is a team of more than 260,000 people who are building career success through commitment, compassion and a desire to make a difference. Join us. Learn more about how you can start doing your life's best work.SM

Primary Responsibilities:

  • Research and interpret healthcare claims payment policy to identify potential overpayment opportunities

  • Perform review of Provider documentation to identify overpayments related to fraud, waste, abuse, billing / coding errors and inappropriate utilization of services, as well as summarize and document specifics of the review

  • Communicate all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations

  • Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance

Note: Candidate must have DRG Coding and Audit Experience to be considered for this role.



Required Qualifications:

  • High School Diploma / GED or higher

  • Current and unrestricted RN license in the state of residency

  • 5+ years of experience as a RN, including experience in an inpatient / acute setting

  • 1+ years of medical DRG coding experience

  • Proficiency with Microsoft Word and Microsoft Excel (ability to create, edit, copy, send, and save documents, correspondence, and spreadsheets)

  • Demonstrated solid knowledge of medical coding DRG,CPT, PCS, HCPC and ICD - 10

  • A designated home work space with access to install secure high - speed internet via cable / DSL

  • DRG Audit Experience

  • CCS or CPC certification

Preferred Qualifications:

  • Bachelor's degree (or higher)

  • Experience with using Milliman Care Guidelines (MCG) or Interqual

  • Experience working with algorithms

  • Managed care experience in utilization management or clinical claims review

  • Quality assurance experience

  • Experience with Microsoft Access (ability to run queries, create macros etc.)

  • Data analysis experience

  • HIPAA experience

  • Experience performing clinical reviews of medical records and supporting documentation from previous post - service determinations

  • Investigative experience, experience talking with physicians or medical providers, reviewing medical claims, and resolving issues pertaining to medical claims and providers

Soft Skills:

  • Demonstrated excellent verbal and written communication skills

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health - related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM


Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer 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.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.


Keywords Optum, Healthcare, Consultant, Recovery, Resolutions, Claims, Operations, Payment Integrity

RN - DRG Recovery / Resolution Consultant - US Telecommute