Manager, Medical Claims Resolution Department – San Antonio, TX

WellMed, part of the Optum family of businesses, is seeking a Manager to join our team in San Antonio, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

This position is responsible for overseeing the day-to-day operations and inventory management of the claims resolution department, with a focus on collaborating with the Utilization Review Department for consistent outcomes. The Manager will ensure timely resolution of provider claims within regulatory and health plan requirements, while also providing inventory reporting and analysis to management. Additionally, this role will involve periodic communication and coordination with other departments to resolve any claims issues. The Manager will provide supervision and guidance to MCR supervisors, ensuring effective management of their teams through team meetings, one-on-one sessions with team members, and disciplinary actions.

This position is full-time, Monday – Friday. Employees are required to work during our normal business hours of 7:00am – 4:00pm. It may be necessary, given the business need, to work occasional overtime. Employees are required to work some days onsite and some days from home.

We offer 1-3 months of on-the-job training. The hours during training will be 7:00am – 4:00pm, Monday – Friday. Training will be conducted onsite.

If you are within a commutable distance to the office at 19500 Ih 10 W, San Antonio, TX, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.

 

Primary Responsibilities:

• Develop and implement departmental processes to ensure compliance with contractual, federal, and state guidelines related to claims resolution and utilization review
• Oversee the quality assurance process for the resolution of claims, ensuring timely and accurate handling of claims and responses in collaboration with the Utilization Review Department
• Continuously assess the staffing needs of the department based on workload and production goals, making adjustments as necessary to maintain compliance
• Establish production and quality goals for each function within the department and monitor and track performance
• Respond to compliance audits for claims resolution to track regulatory compliance and provide management reporting
• Serve as a resource to departmental supervisors and staff for questions related to contractual interpretation, process administration guidelines, workflow, and operational issues
• Act as a liaison for communication with other departments, including the Utilization Review Department, business associates, health plan partners, and state and federal entities
• Manage and coordinate any testing required for changes or upgrades to the claims resolution platform
• Participate and collaborate with internal teams associated with Network Operations and external departments within WellMed
• Stay informed about new and pending legislation that may impact the guidelines followed by Third Party Administrators related to claims resolution and utilization review
• Perform any other related duties 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:

• High School Diploma / GED OR equivalent work experience
• Must be 18 years of age OR older
• 5+ years of experience with claims resolution and utilization review in a managed care setting
• 3+ years of experience in a lead OR supervisory capacity
• Knowledge of federal and state laws regarding claims resolution and utilization review
• Proficiency in Microsoft Office programs, including Microsoft Word, Microsoft Excel, Microsoft Outlook, Microsoft Access, and Microsoft PowerPoint
• Ability to work Monday – Friday, during our normal business hours of 7:00am – 4:00pm

 

Telecommuting Requirements:

• Reside within a commutable distance to the office at 19500 Ih 10 W, San Antonio, TX
• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

 

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

 

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.

 

 

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

 

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

 

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