Claims Business Process Consultant

This position is Field Based and requires regular travel to various locations as part of your daily responsibilities.

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together

Position Summary

The Medicaid Health Plan Claims Business Process Consultant is responsible for reviewing, and analyzing claims submitted under the Medicaid program. This position ensures compliance with federal and state Medicaid regulations, accuracy of claim payments, and timely resolution of claim issues. The Claims Business Process Consultant collaborates closely with internal partners across the Health Plan and National support team to resolve discrepancies and support optimal claims management.

This position is full-time (40 hours/week) 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 - 5:00 pm.

Primary Responsibilities:

• Review and process Medicaid health plan claims to ensure accuracy, completeness, and compliance with all applicable guidelines and policies
• Investigate and resolve claim discrepancies, denials, and appeals, coordinating with providers, members, and other stakeholders as necessary
• Apply knowledge of Medicaid billing codes, reimbursement methodologies, and coverage criteria to adjudicate claims appropriately
• Identify patterns of errors, fraud, waste, or abuse and escalate as needed to management or the Special Investigations Unit (SIU)
• Maintain up-to-date knowledge of Medicaid program changes, policies, and procedures to ensure ongoing compliance
• Document claim decisions and actions in the claims processing system with accuracy and attention to detail
• Respond to inquiries from providers, members, and internal teams regarding claim status and resolution
• Contribute to process improvement initiatives by identifying inefficiencies or recommending enhancements in claims operations
• Conducting provider training and education

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
• Must be 18 years of age OR older
• Must have a valid driver's license
• 2+ years of customer service or provider service experience
• 2+ years of experience in medical health insurance claims processing
• Experience with Medicaid regulations, billing codes (ICD, CPT, HCPCS), and claims adjudication processes
• Proficiency with claims management software
• Experience with Microsoft Excel (Create and Edit Spreadsheet, Use Formulas, create Pivot Tables)
• Must be able to travel up to 25% of the time within NJ, travel will be conducted by driving
• Ability to work full-time (40 hours/week) 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 - 5:00 pm.

Preferred Qualifications:

• Experience with Medicaid plans
• Experience in a Provider facing role
• Experience in ownership of internal/external stakeholder relationships

Soft Skills:

• Works independently and collaboratively in a fast paced environment
• Exceptional attention to detail and a commitment to accuracy
• Excellent analytical, organizational, and communication skills

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  $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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.

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