Claim EDI Process Capability Lead – Remote

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.

 

On the one hand, no industry is moving faster than health care. On the other, no organization is better positioned to lead health care forward than Optum and UnitedHealth Group. That’s what makes this opportunity so applause worthy. We have hundreds of business verticals across our matrixed organizations that are bringing thousands of new ideas, services and products to the marketplace every year. Our goal is simple. Use data and technology to help drive change and make the health care system work better for everyone. When you join us as a Senior Capability Analyst, you’ll be engaged in a complex business model that is highly adaptable to build solutions that meet their customer needs in a competitive and effective way. 

 

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 

 

Primary Responsibilities: 

This role will challenge your ability to work in a complex environment of claim processing operations where we are expanding capabilities rapidly to meet customer requirements and grow the business. You’ll need flexibility, agility and the ability to adapt to change while maintaining solid relationships with stakeholders in a highly cross-matrixed environment

People in this position are responsible for claim intake, processing and outbound capabilities and day-to-day claim adjudication operations. Positions in this function play a critical role in our ability to deliver claim processing services to clients and to manage internal business cross-capability partnerships to execute on client commitments and performance measures. Accountable for delivering scalable, sustainable, financially sound solutions that solve client requirements and enable successful claims processing services product delivery and/or internal business function performance, while driving adoption with internal business partners.  Accountable for the day-to-day oversight of claim inbound and outbound operations/production and inventories.

• Claim Data and Claim Correspondence Inbound and Outbound Processing
  • Day-to-day operation of claim and claim correspondence intake/outbound processing to ensure streamlined, compliant and timely receipt of all inbound claims and claim correspondence as well as delivery of outbound encounter and claim files, claim correspondence, and payment files
  • Daily monitoring of process control reports and escalation of any issues identified for swift remediation
• Business Operations Design
  • Develops relationships with claim inbound/outbound teams including clearinghouses, mail room offices, digital-portal teams, workflow teams, Health Plan partners, and IT batch processing partners involved in intake/outbound processing
  • When required, engages with new clients to document process requirements
  • Solutions and builds claim and correspondence inbound/outbound processing solutions enabling scale and quality while meeting business requirements
• Industry Knowledge Expert
  • Knowledgeable of industry standards for electronic claim file exchanges and layouts (EDI 837P and 837I claims and encounters)
  • Knowledgeable of industry standards for additional electronic file exchanges including payment files (EDI 835) 
  • Knowledgeable of industry standards for additional electronic file exchanges including authorizations (EDI 278) and eligibility (EDI 270/271)
• Knowledge of Applicable Laws and Regulations
  • Demonstrate knowledge of applicable legal/compliance requirements, and the penalties associated with non-compliance (e.g., HIPAA, CMS, Medicaid and Commercial state regulations, performance guarantees, service level agreements)
  • Maintain awareness of changes to applicable laws and regulations impacting claims business processes (e.g., Healthcare
    Reform/PPACA, CMS, state regulations)
• Data Driven Decision Making and Business Communication
  • Strategic thinking with ability to align claim capabilities to business goals
  • Uses pertinent data and facts to identify and solve a range of problems within area of expertise
  • Ability to synthesize complex information into actionable insights and communicate in a manner clear and appropriate for targeted audience
  • Prioritizes and organizes own work to meet deadlines

 

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: 

• 10+ years of experience in claim inbound and/or outbound EDI operations – medical claims preferred
• Demonstrated experience designing complex business operations/processes – with focus on scale to enable cost-controlled growth.  Enabling appropriate operational controls and metrics 
• Vendor management experience

 

Preferred Qualifications:

• Experience with multiple products (Medicare, Medicaid, Duals, Commercial)
• Experience working across multiple Health Plan payors
• Familiarity with Risk Bearing Entity (RBE) and/or Value Based Care (VBC) business models

 

*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. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $71,200 to $127,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

 

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

 

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.