Job Abstract

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 startCaring. Connecting. Growing together.

We are in search of a self-directed professional with a strong work ethic and the ability to thrive under pressure situations. If you want to work in a position that offers challenging work and a variety of problems to solve and troubleshoot, this might be the right role for you.

Youll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Accountable for ownership of provider claim projects in an end to end process, from initial provider contact, identification of claim payment issue, facilitation of resolution of claim payment issues and communication of outcome to provider
• Ability to educate provider on details of UHG reimbursement policies, billing requirements, etc... Understand and specializing in multiple markets with the intent to know and understand the physicians, facilities and ancillary providers and the nuances of their contracts and the related claim issues
• Interact directly with market providers and internal staff in the resolution of claim issues
• Maintain ongoing communication with providers throughout the project process
• Research claims to determine accuracy and identify root cause of any claim payment issues
• Enable team members to ensure consistent quality service to UHGs participating providers
• Resolve complex issues, support fellow CPMs, providing feedback and training as needed
• Respond to complex escalated provider written, electronic and phone contacts within current turnaround times
• Research, analyze, identify root cause and coordinate resolution of claim issues with business partnerswithin current turnaround times
• Gather information to properly analyze issues. The ability to prioritize, and multi-task effectively is required for success in this position
• Work with provider to gather information, prepare and submit claim projects (20 or more claims) to the Claims Resolution Team (CRT) when appropriate
• Ensure accurate project submission based on the identified root cause
• Monitor progress of project and provide periodic updates to provider contact
• Upon project completion by CRT, audit project results, send rebuttals as necessary
• Prepare and send project results to provider contact, Conduct final provider call to review project outcome and ensure provider satisfaction with project results
• Work collaboratively with CPM and resolution partners to resolve complex claim reimbursement issues that require additional assistance from other Departments within UHG
• Accountable for accurate documentation and routing of issues to appropriate resolution partners. Maintain daily tracking and documentation of all project activities and communications within the DCT
• Complete all communications and follow up activities within established TAT's
• Support and represent CPM on conference calls and special projects as assigned
• Serve as primary point of contact for Market Service Agent (MSA), Network Service Agent (NSA) and Senior Service Agent (SSA) in resolution of claims project issues; check status of critical issues. Participates in conference calls with MSA, NSA, and SSA & NM to obtain information and improve service
• Meet or exceed all productivity and quality assurance expectations and guidelines
• Successfully completes and effectively utilize all required training
• Maintain compliance with all Federal (i.e. HIPPA), State (i.e. fee schedule disclosure laws), and local regulations and laws
• Other duties as assigned

Youll 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 higher
• 5+ years of experience with physician, ancillary and facility contracting methodologies, contract loading and contract interpretation
• 2+ years of experience with claims system configuration and appropriate loading methodologies of complex contracts into the system
• 2+ years of experience in USP/Cirrus claims as follows: claim payment, history review, and complex adjustment review, manual claim calculations, review provider contract set up and selection
• 2+ years of experience with researching, understanding and communicatingUHGs reimbursement policies
• Intermediate level of proficiency with medical terminology, referral and authorization practices, standard-coding methodologies (CPT, ICD-9, HCPCS and revenue)
• Intermediate level of proficiency with MS Office including Word, Excel, Access, etc

Preferred Qualifications:

• 5+ years relevant experience, including three in medical claims reimbursement and minimum of two years in direct customer service
• Experience in team interactions and improvement methods/projects
• Ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
• Ability to interpret electronic data and apply to health care claim processing
• Superior skills in UHGs processes, systems, and products, including but not limited to: Knowledge Central, RPU2U, SOS Help, Lotus Notes, WAND, CCS View, IDRS, TDARS, EDSS, NDB

Soft Skills:

• Ability to work independently and make sound decisions in a fast paced environment
• Proven ability to manage multiple tasks, prioritize and meet deadlines under a heavy workload
• Excellent follow up, organizational and change management skills
• Proven problem solving skills are key to success in this role
• Excellent Customer Service skills, ability to handle irate callers, gain the callers trust, take ownership of callers issue and manage through to resolution
• Clear spoken voice and solid communication skills, both verbally and written

#RPO #Green