Optum ยท 21 hours ago
Senior Recovery Resolution Analyst
United States
Full-time
Remote
Mid, Senior Level
$28.27/hr - $50.48/hr
2+ years expOptum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The Senior Recovery Resolution Analyst will be responsible for auditing cases, ensuring compliance with reimbursement policies, and providing clinical expertise in the claims adjudication process.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Responsible for auditing all cases with findings/ no findings prior to closure, provide feedback to individuals, review individual and peer historical performance. Provides coaching sessions as per the root cause analysis of identified errors
Determines appropriate level of service utilizing Evaluation and Management Coding principles
Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
Responsible for Clinical and Coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review
This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
Performs audit of clinical coverage review of post-service, pre-payment claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns
Performs audit of clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing
Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review
Provides clinical support and expertise to the other investigative and analytical areas
Participate in team and network meetings, engaging in a collaborative work environment
Serves as a clinical resource to other areas within the clinical investigative team
Qualification
Required
High School Diploma / GED
Certified Coder AHIMA or AAPC Certified coder (CPC, CCS, CCA, RHIT, CPMA, RHIA, CDIP)
Must be 18 years of age OR older
2+ years of experience as AHIMA or AAPC Certified coder (CPT/HCPCS/ICD - 10/CM/PCS coding experience)
2+ years of practical experience interpreting reimbursement policies and provisions for Medicare, Community and State, and Employer and Individual
Experience with Fraud Waste & Abuse or Payment Integrity
Experience with Microsoft Word (create correspondence and work within templates), Microsoft Excel (data entry, sort / filter, and work within tables) and Microsoft Outlook (email and calendar management)
Medical record review experience
Understanding of Waste & Error principles
Knowledge of Medicare reimbursement methodologies, i.e. Resource Based Relative Value System (RBRVS)
Knowledge of health insurance business, industry terminology, and regulatory guidelines
Ability to work full-time (40 hours/week), Monday - Friday. Employees are required to have flexibility to work on any of our 8-hour shift schedules during our normal business hours of 8:00 AM - 5:00 PM. It may be necessary, given the business need, to work occasional overtime
Preferred
Nurse (RN, LPN) with unrestricted license
2+ years of auditing professional claims experience
2+ years of experience in Quality/Quality Management medical record review
1+ years of experience of UHC platforms - COSMOS, Facets, CIRRUS, UNET, ISET and CPW
Investigational and/or auditing experience, including government and state agency auditing
Experience in training, mentoring and/or development with adult learners
Proficiency in Microsoft Excel (VLOOKUP's, pivot tables, etc.), Microsoft OneNote (utilize and update information), Microsoft Teams
Ability to assist with focusing activities on strategic direction and achieve targets demonstrated data management and/or project management skills
Benefits
Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
Company
Optum
Optum is a healthcare company that provides pharmacy services, health care operations, and population health management. It is a sub-organization of UnitedHealth Group.
10001+ employees
H1B Sponsorship
Optum has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (648)
2024 (559)
2023 (620)
2022 (851)
2021 (593)
2020 (438)
Funding
Current Stage
Late StageLeadership Team
Daniel Castillo
Chief Executive Officer, Optum Care Delivery
J
Jay Green
Chief Financial Officer
Recent News
2025-11-29
2025-11-19
2025-11-07
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