Risk Operations Leader - Remote

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. 

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities: 

Manage and Evaluate Risk Operations Programs and Strategies 

• Develop and work with project managers, IT (analysts, integration and reporting teams), analytics and operational stakeholders for implementing health plans, changes in operational systems, and maintaining EPIC systems
• Review and monitor data, providing analysis of issues, risks, mitigation, and resolutions of problems
• Establish and/or implement internal and/or external service level agreements to ensure ability to monitor and measure program performance (e.g., turnaround time; quality; effectiveness)
• Review and monitor contractual obligations related to service level agreements
• Analyze operational performance on relevant criteria (e.g., targeted financial metrics; quality indicators; performance guarantees and/or incentives) to determine overall effectiveness, make necessary changes, and identify opportunities for new programs or program consolidation or expansion

Build/Maintain/Manage Relationships with Risk Operations Stakeholders 

• Partner with multiple stakeholders related to claims and risk operations: claims payment/billing, health plan and provider contracting, director of health plan contracting, utilization management, provider relations
• Partner with contracted health plans to resolve issues related to claims and risk operations
• Partner with financial teams to manage and optimize risk operations performance
• Provide standard performance reports (e.g., scorecards) to update relevant internal and/or external stakeholders on the status of work projects
• Conduct regular meetings (e.g., JOCs; QBRs) with relevant internal and/or external stakeholders to review and discuss updates and outstanding issues (e.g., project implementation readiness; compliance and/or quality audit results; out-of-compliance issues; staffing issues)
• Develop corrective action plans to address and/or resolve relevant internal and/or external stakeholders' concerns or issues regarding operational issues
• Partner with relevant internal and/or external stakeholders to develop and/or review operational strategies, programs, and plans (e.g., affordability initiatives; quality programs; projected resource needs)
• Partner with vendors that support claims, call center, configuration teams - administrative functions for claims (inbound/outbound mail), EPIC technical support counterparts

Support/Develop/Ensure Compliance with Operations Policies, Procedures, and Regulations 

• Demonstrate understanding of and adhere to relevant health plan and claims policies, procedures, benefit builds, and regulations
• Communicate and coordinate with and/or help internal and/or external partners interpret contractual requirements to ensure compliance with contractual and regulatory stipulations
• Monitor and/or report on-going compliance and related outcomes (e.g., claim denials; complaints; clinical metrics) to relevant internal and/or external stakeholders (e.g., regulatory agencies; customers; vendors)

Review/Manage/Drive Risk Operations Efficiency, Quality, and Financial Performance 

• Manage and optimize risk operations performance: Analyze budget performance and variances throughout the fiscal year and recommend and/or make necessary adjustments and corrections
• Utilize stakeholder input to help shape and implement continuous improvement in operational quality and financial performance
• Ensure internal partners and/or external vendors adhere to business and contractual agreements
• Work with relevant internal partners (e.g., Finance; Underwriting) to identify resource requirements and/or create budgets and forecasts

Claims and Configuration and Customer Service Teams 

• Management and operational oversight of the following teams to manage and optimize risk operations performance
• Configuration: how system is configured to support claims processing including benefits, eligibility, capitations R&R, and provider data management, and contract configuration
• Claims: claims processing, denials, appeals, and encounter submissions
• Customer service: call handling for claims eligibility, benefits, authorizations, and provider network
• Provide guidance, expertise, and/or assistance to claims and configuration and call center teams to ensure programs and strategies are implemented and maintained effectively

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:

• 3+ years of hands-on Epic Tapestry experience
• 3+ years of Self-service functions in SlicerDicer within EPIC, specifically: AP Claims module and Covered Members module
• 3+ years of with Tableau and BI Portal

Preferred Qualifications:

• Experience with NICE CX One: customer service platform
• Familiarity with SQL

*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 salary for this role will range from $112,700 to $193,200 annually 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.