Consultant Business Systems – Medicare, Medicaid

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.

The Business Analyst will work closely with business stakeholders, SMEs, and technical teams to analyze healthcare processes, identify revenue opportunities, and support operational excellence across claims adjudication, appeals, audit recovery, and FWA detection. The role requires solid analytical skills, problem solving abilities, and solid domain expertise in US healthcare programs.

Primary Responsibilities:

• Analyze and document business requirements related to claims adjudication, appeals processing, audit recovery, and FWA (Fraud, Waste, and Abuse)
• Identify revenue optimization and cost avoidance opportunities through data analysis and process evaluation
• Collaborate with operational, compliance, and technical teams to translate business needs into functional specifications
• Support policy interpretation and application across Medicare, Medicaid, State programs, or Commercial US healthcare (expertise in at least one required)
• Conduct root cause analysis for claim inaccuracies, payment variances, and operational gaps
• Support audits, recoveries, and regulatory reviews by ensuring data accuracy and traceability
• Assist in UAT, validation activities, and post implementation reviews
• Prepare clear documentation, reports, and presentations for stakeholders
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• Hands-on experience in:
  • Claims adjudication
  • Appeals and grievance processing
  • Audit and recover operations
  • Fraud, Waste, and Abuse (FWA / FWAD)
• Experience working in cross functional and fast paced environments
• Solid knowledge of at least one of the following:
  • Medicare
  • Medicaid
  • State healthcare programs
  • US Commercial healthcare
• Proven solid problem solving and analytical skills
• Proven ability to interpret healthcare policies, reimbursement rules, and claim edits
• Proven excellent written and verbal communication skills

Preferred Qualifications:

• Undergraduate degree or equivalent experience
• 7+ years of experience in business system analysis and health care management
• Experience with healthcare claims platforms and data tools
• Familiarity with CPT, HCPCS, ICD, modifiers, and reimbursement logic
• Exposure to compliance and regulatory requirements

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.

#NJP #NIC