Recovery Resolution Sr. Analyst- Clinical
Remote/telecommute
Position background - What does this position accomplish for the business? Investigate Optum Waste and Error stopped claims by gathering information researching state and federal guidelines and following internal procedures to determine the viability of the claim for further review in a production environment.
Position overview - What will the candidate be working on while on assignment?
Perform clinical review of professional or facility claims vs. medical records to determine if the claim is supported or unsupported. Will be working with WellCare External Commercial team consisting of other certified coders.
What are the top responsibilities for this position?
- Clinical Case Reviews -75
- Perform clinical review of professional or facility claims vs. medical records to determine if the claim is supported or unsupported.
- Maintain standards for productivity and accuracy. Standards are defined by the department.
- Provide clear and concise clinical logic to the providers when necessary.
- Other internal customer correspondence and team needs - 15
- Attend and provide feedback during monthly meetings with assigned internal customer department.
- Provide continuous feedback on how to improve department relationships with internal team members and departments.
- Continue education - 10
- Keep up required Coding Certificate and/or Nursing Licensure.
- Complete compliance hours as required by the department.
What software tools/skills are needed to perform these daily responsibilities? Microsoft Office Excel Outlook etc.
How will performance be measured? monthly audits of reviewed work with a 95 or higher accuracy rate for goal
What skills/attributes are a must have?
Required Coding Certificate or Nursing Licensure for example:
- Certified Professional Coder CPC
- Certified Inpatient Coder CIC
- Certified Outpatient Auditor COC
- Certified Professional Medical Auditor CPMA
- Certified Coding Specialist CCS
What skills/attributes are nice to have and will set a candidate apart? 3 years former coding experience or auditing experience
What soft skills will an ideal candidate possess?
- Working knowledge of medical terminology and claim coding.
- Strong written and verbal communications skills.
- Strong customer service skills.
- Ability to work in a team.
- Proficient with personal computers
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.