Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best.
Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
Positions in this family include those responsible functions in Behavioral Health such as Care Advocacy, Employee Assistance Programs and behavioral health consulting.
You\'ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Investigate, review and provide data-trend expertise in a review of post-service, pre-payment or post-payment claims
- Interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make recommendation decisions based on findings
- Identifies overt billing trends for Fraud, Waste, Abuse, and/or Error identification, and recommends providers to be flagged for review
- Identifies updated clinical analytics opportunities and participates in projects necessary by client/other departments
- Ability to navigate through multiple claims applications (COSMOS, UNET, Facets, etc.), to aid in research and work independently on making decisions on complex cases
- Participates in client/network meetings, which may include process changes
- Analyze/research/understand how a claim was identified by Payment Integrity and determine appropriate resolution path
- Work with applicable business partners to obtain additional information relevant to the Payment Integrity case in order to drive resolution (e.g., Network Management, Claim Operations, OGS, UHCPI)
- Comprehend and adhere to applicable federal/state laws and regulations (e.g., DOI, ERISA, HIPAA, CMS)
- Participates in additional projects as needed, and assumes additional responsibilities as assigned
You\'ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- 2+ years of investigative experience
- 1+ years of experience working with healthcare claims data
- Demonstrated advanced proficiency with MS Excel, including v-lookups, pivot tables, and formulas
Preferred Qualifications:
- Behavioral Health experience
- Experience with healthcare FWAE (Fraud Waste Abuse & Error) or with Payment Integrity
- Experience working with relational databases and database structures (such as SQL, Oracle, Teradata)
Note: All employees working remotely will be required to adhere to UnitedHealth Group\'s Telecommuter Policy.
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. We offer a comprehensive benefits package and recognize that our employees are our greatest asset.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
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Salary: USD 72000 - 108000 per year
Experience: 3 years required
