Optum · 18 hours ago
Recovery Resolution Consultant
United States
Full-time
Remote
Mid, Senior Level
$71K/yr - $127K/yr
5+ years expOptum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The Recovery Resolution Consultant will perform DRG validation reviews, provide clinical and coding expertise, and serve as a Subject Matter Expert in medical record reviews and Payment Integrity initiatives.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Perform DRG validation reviews and confirm appropriate diagnosis related group (DRG) assignments
Maintains current working knowledge if ICD-10 coding principles and CMS regulations
Investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical records review
Serve as a Subject Matter Expert (SME), performing medical record reviews to include quality audits, as well as validation of accuracy and completeness of all coding elements, and medical necessity reviews
Responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development
Serves cross-functionally with Medical Directors, and sometimes Utilization Management, as well as other internal teams to assist in identification of overpayments
Serves as a SME for all Payment Integrity functions to include both Retrospective Data Mining, as well as Pre-Payment Cost Avoidance
Identifies trends and patterns with overall program and individual provider coding practices
Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable opportunity
Qualification
Required
High School Diploma / GED OR equivalent work experience
Must be 18 years of age OR older
Inpatient Coder with RHIT, RHIA or CCS Certification(s)
Certified Professional Coder (CPC)
5+ years of experience in the health insurance industry
2+ years of experience with health insurance claims
2+ years of experience with medical records review / auditing including MS-DRG coding validation and / OR Acute Inpatient Coding experience
2+ years of experience using Facets claims platforms with Medicaid, Medicare, and Commercial lines of business
2+ years of facility claims experience
Proficiency in performing financial analysis / audits including statistical calculation and interpretation
Ability to work Monday - Friday, during our normal business hours of 7:00am - 5:00pm CST. It may be necessary, given the business need, to work occasional overtime
Preferred
Registered Nurse
2+ years of experience in Utilization Management
Experience working with federal contracts
CES (Claims Editing System) SME, or SME in another clinical claims editing system
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
Company data provided by crunchbase