Claims SME (HCBS) - San Juan, PR

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.

This is an opportunity that's all about where you've been. Your experience. Your potential. Your skills. Because on the team at UnitedHealth Group, your potential and your impact can be career changing. No company has put together better teams of passionate, energetic and all out brilliant Claims Representatives. This is where you come in. We'll look for your experience and expertise to help keep our service levels and accuracy extremely high. We'll also look for your ideas on how to constantly evolve our claims processes. We'll back you with the great training, support and opportunities you'd expect from a Fortune 5 leader. 

The SME from the Claims department will update the applicable UHC systems that impact claim payment. Other responsibilities include: conducting audits and providing feedback to reduce errors and improve processes and performance, and may be responsible for representing the W&E area on operational excellence and improvement projects. Supports training for process knowledge training to current and new associates.

Primary Responsibilities:

• Ability to handle most claim types / rework / issues that are submitted to the team you are supporting
• Manage team Questions / Escalations SharePoint / Email
• Submit requests to have information validated or requested
• Submit system issues
• Submit P&P update requests
• Submit new macro requests or macro updates
• Review team quality rebuttals and support team remediation plans / initiatives
• Perform desk visits or coaching and development for team members as needed
• Complete required individual development courses / trainings
• Meet and maintain minimum quality and productivity standards
• Provide assistance managing team and department workflow
• Host / Attend meetings such as, but not limited to: 
  • Quality related meetings 
  • P&P Calls
  • SME meetings

*** ENGLISH PROFICIENCY ASSESSMENT WILL BE REQUIRED AFTER APPLICATION ***

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:

• 1+ years of experience in the healthcare industry
• 1+ years of experience in a production environment
• 1+ years of experience analyzing and solving customer problems in an office or customer service environment

• 6+ months of experience working in HCBS claims processing 

• Microsoft Excel proficiency (filter, sort, create and edit spreadsheets) 
• Proficient in verbal and written English skills

Preferred Qualifications:

• Training experience 
• Knowledge of Managed Care/ Medicaid / Medicare / Commercial rules and regulations
• Inventory and audit management 
• Proven ability to utilize complex database systems and claims platforms simultaneously including (Ex. CSP Facets)
• Proven problem and Analytical Skills
• Proven ability to work independently and as a team player

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.