Employment Spot

Job Description

UnitedHealth Group is an innovative leader in the health and well-being industry, serving more than 55 million Americans. Through our family of companies, we contribute outstanding clinical insight with consumer-friendly services and advanced technology to help people achieve optimal health. Ingenix is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
 
If you get excited about the life transforming potential of bringing health care information to the right place, at the right time, to support crucial decisions, welcome to Ingenix.
 
We're one of the largest and fastest growing health information companies and the only organization in our industry with the information, technology and consulting expertise to solve the most significant challenges in health and human services.
 
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.
 
Senior Nurse Recovery/Resolution Analyst - Portland, ME
 
Primary Responsibilities:

• Chiefly responsible for reviewing provider dispute medical documentation for accuracy of original claim submission and provider's billing practices
• Extensive research on insurance policies, provider billing manuals and provider contracts
• Summarizes and documents specifics of the review
• Reviews and resolves provider disputes in a timely manner consistent with the goals of Ingenix and its clients
• Manages own PR case work load, ensuring expedient resolution for all provider disputes
• Communicates directly with providers regarding disputes
• Creates weekly analysis of case log, working with PR Manager to ensure appropriate rate of closure
• Attends onsite reviews
• Attends and/or participates in hearings
• Participates in letter QA and generation process
• Works with other PR personnel on a daily basis and provides assistance with all areas of PR tasks when needed
• Works as an integral part of the Client, Algorithm, and Letter Factory Teams
• Participates in early stage client/project planning
• Works collaboratively with PR Manager, Client Manager and Algorithm Team to communicate disputes, trends, concerns, ideas
• Participates in all staff meetings
• Participates in all algorithm/letter training sessions
• Participates in innovation processes to develop new tools and strategies to enhance PR performance
• Actively identifies and shares best practices
• Develops tools for active knowledge sharing and management

Job Requirements

Qualifications:

• RN degree required and current license
• 2 - 5 years experience reviewing providers medical and pharmacy dispute documentation for accuracy of original claim submission and provider's billing practices
• 2 - 5 years medical claims coding & processing experience (ICD 9 , CPT, HCPCS, revenue codes, DRG, POS, NDC)
• 2 - 5 years experience working with Medicaid, Medicare and Commercial Insurance entities as well as with paid claims data
• 1 - 3 years clinical background required
• Excellent research skills including but not limited to insurance policies and regulations (State and/or Federal specific, provider billing manuals, provider contracts & different websites)
• Excellent oral and written communication skills as well as experience with provider negotiation/settlement agreements for overpayments
• Outlook, MS Word, Excel, Internet research required as well as having a good comfort with learning different internal systems/applications
• Extremely organized, detail oriented, flexible, positive and multitasking skills are required
• Ability to work individually as well as collaboratively on multidisciplinary teams
• Ability to occasionally lift 25 lb.
• Certified Medical Coder a plus but not required