Energize your career with one of Healthcare’s fastest growing companies.
You dream of a great career with a great company – where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it’s a dream that definitely can come true. Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our service centers, improve our service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up.
This opportunity is with one of our most exciting business areas: Optum – a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader.
Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their healthcare needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.
Positions in this function are responsible for all aspects of Quality Control within the Claims job family. Generally audits are conducted of production staff equal to or lesser than the salary grade level so indicated.
- Analyze, create and manage audit results / reporting and as required conduct audits to improve processes, results, and team performance
- Perform data analysis of quality and claims history to identify key trends and identify and drive remediation with business partners
- Work with manager and team members to create accurate reports that detect and identify trends, analysis of those trends and risk mitigation recommendation for operational and business review / planning
- Use pertinent data and facts to identify and solve a range of problems within area of expertise
- Lead projects to completion by coordinating cross functional data and reports into meaningful deliverables
- Provide accurate data by validating information in order to provide output that drives business results
- Support short-term and long-term operational / strategic business activities through analysis
- Develop, recommend and implement business solutions through research and analysis of data and business processes
- Serve on applicable cross-organizational quality committees / work groups to identify / communicate common quality issues, trends and patterns (e.g., Quality Council)
- Investigate non-standard requests and problems with some assistance from others
- Perform queries on relevant claims systems in order to obtain relevant information for audits
- Utilize data and algorithmic guidelines as defined by Advanced Analytics to identify potential anomalies, either pre or post pay
- Validate claims data, member data, provider data against information from claims processing or business processing systems to ensure that data / decisions / payment and recovery / settlement information is accurate
- Analyze claims / member / provider data against applicable policies and regulations to identify potential issues (e.g., member benefits, provider contracts, billing anomalies, payment accuracy, claims processing system issues, state mandates)
- Review history of related claims to pull in and understand additional claims-related information
- Maintain reporting infrastructure, as appropriate (e.g., SharePoint, Access databases)
- Calculate dollar amount of financial errors / defects
- Develop and deliver fact-based audit determinations in an objective, non-confrontational manner
- Escalate issues identified during the audit cycle or rebuttal process to applicable stakeholders, as appropriate (e.g., Subject Matter Experts, Operations Team, Quality Team, business partners, team leads)
- Ensure compliance with applicable audit and rebuttal timelines (e.g., calibration timelines, rebuttal timelines / form completion, workflows, turnaround time)
- Achieve production quality goals / metrics (e.g., audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)
- Provide supporting documentation for audit findings
- Manage audit inventory to ensure proper workload balance, coverage and closure
- Identify / communicate escalated errors / defects and ensure proper resolution, as needed (e.g., calibrations, rebuttals, appeals)
- Identify, communicate and implement opportunities for improving internal audit / rebuttal processes within the Quality team
- Look for opportunities to provide additional value and anticipate needs
- Work independently with minimal supervision
- Bachelor's Degree (or higher)
- 4+ years prior experience in a transactions-based operation
- 4+ years of experience within a matrix organization, healthcare, or insurance company
- 2+ years data analysis and reporting design experience
- 2+ years of experience managing multiple small projects / requests
- Prior knowledge / experience with account-based products
- Experience collaborating & partnering with internal customers
- Licenses and Certification or equivalent (ex: Certified coding professional, RN / LPN / LVN, Certified Quality Analyst, Six Sigma Green Belt)
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.