Provider Outreach – Data Mining

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.

This role performs Clinical Procedure Coding research and outbound calling activities related to Data Mining programs. The successful candidate will review all types of medical claim payments from a research perspective in support of auditors and new outreach ideation. This role requires strong interpersonal skills combined with deep Clinical Procedure Coding, billing and claim platform knowledge to support outbound calling activities. These outbound calling activities relate to a varied and specialized set of unlikely billing scenarios. The successful candidate should have prior experience within the U.S. HealthCare industry with specific proficiency within reimbursement policy, provider contracts and clinical coding. Expertise with regard to navigating and understanding UHG core claims platforms (UNET, COSMOS, CSP, NICE etc.) is an advantage for this role.  Prior experience within Payment Integrity, Network Management or Claims Operations is a distinct advantage. All the above is undertaken in collaboration with various matrix business partners.

Primary Responsibilities:

• Obtain all available data relevant to determine suitability and conduct Outreach call
• Work with payers/providers to review claim information and identify issues related to payment accuracy
• Design and implement appropriate outreach calling strategies specific to providers and outreach    scenarios to determine advantageous call success rates
• Assesses and interprets customer needs and requirements
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Use pertinent data and facts to ideate, identify and solve a range of problems within area of expertise
• Ability to communicate the outcome of this research in a manner suitable for the intended audience
• Identify potential concepts for retrospective and prospective savings through individual ideation and from several perspectives such as correct billing, clinical procedure coding, network contracting, policy reimbursement, medical documentation requirements, industry and federal guidelines
• Advise auditors on billing and coding guidelines to identify potential overpayment scenarios
• Document and communicate outcomes of outreach reviews to applicable stakeholders

***ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION***

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 health care outreach experience designing call strategies and conducting calls to providers
• 2+ years of health care experience working with claims data and / or medical codes  
• 2+ years of experience researching medical claims information both internal and external
• 1+ years of experience working with processing and reviewing medical claims platforms
• Experience analyzing claims to determine trends / patterns
• Experience reading and interpreting medical bills and records, provider contracts, fee schedules, and claim payment policies
• Professional proficiency in both English and Spanish (bilingual)
• Computer proficiency in Microsoft Office including Word (create documents), Excel (data entry) and Outlook (send email / calendar utilization)  

Preferred Qualification:

• Experience with Pharmacy billing

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.

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.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.