Senior Enrollment Eligibility Specialist

This position is National Remote. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. For all hires in Minneapolis, Virginia, Maryland, or Washington, D.C. area, you will be required to work in the office for a minimum of four (4) days per week.

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Senior Enrollment Eligibility Specialist is responsible for researching, analyzing, and resolving Medicare Prescription Payment Plan (M3P) member concerns related to enrollment, eligibility, participation, and program administration. Serving as a subject matter expert (SME) in M3P processes and CMS regulations, this role partners closely with internal teams to deliver timely, accurate, and compliant resolutions while ensuring an exceptional member experience.

This position is full-time, Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 6:30 pm CST. It may be necessary, given the business need, to work occasional overtime. Must work one weekend shift, 3 hours a day, (Saturday and Sunday) a month.

We offer 3 - 4 weeks of paid on-the-job training. The hours during training will be 8:00 am to 6:30 pm CST, Monday - Friday. Training will be conducted virtually from your home.

Primary Responsibilities:

• Review and investigate M3P-related grievances forwarded by the OptumRx Grievance Team.
• Research member concerns regarding enrollment, eligibility, participation, and program administration using RxClaim, the M3P Portal, and other applicable systems.
• Validate information, identify root causes, and determine appropriate resolutions for member issues.
• Review election and enrollment forms to ensure submission accuracy and compliance with program requirements.
• Determine M3P application eligibility, coverage allowances, and effective enrollment dates.
• Ensure compliance with established service level agreements, including:
• Interpret and apply CMS regulations, Medicare guidance, and internal policies when making case determinations.
• Conduct quality reviews to ensure established standards and compliance requirements are met.
• Analyze grievance trends, identify process improvement opportunities, and prepare reports as needed.
• Collaborate with internal teams to resolve complex cases and improve operational efficiency.
• Participate in special projects and additional responsibilities as assigned by management.

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
• 3+ years of experience in a related environment (i.e. office, administrative, clerical, customer service, etc.) using phones and computers as the primary job tools
• 1+ years of experience processing medical, dental, prescription or mental health claims
• Experience in understanding and explaining claims details
• Experience investigating coverage and make determinations on appeal reviews
• Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications
• Advanced knowledge of Microsoft Excel, including data management, reporting, formulas, and analysis tools
• Able to work weekends and accommodate flexible scheduling requirements to support organizational needs
• Ability to work full-time, Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00 am - 6:30 pm CST. It may be necessary, given the business need, to work occasional overtime. Must work one weekend shift, 3 hours a day, (Saturday and Sunday) a month

Preferred Qualifications:

• Experience using RxClaim system

Telecommuting Requirements:

• 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.

Soft Skills:

• Ability to communicate findings clearly and effectively through reports, presentations, and written documentation.
• Strong attention to detail with the ability to ensure data accuracy and integrity.
• Demonstrates the ability to adapt quickly to changing priorities, deadlines, and work environments.
• Maintains a positive and productive approach when managing multiple responsibilities.

*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 hourly pay for this role will range from $20.00 to $36.00 per hour 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.