Clinical Appeals and Grievances (analyzing, reviewing appeals / grievances) Review of coding edits and reimbursement issues Works with less structured, more complex issues Solves moderately complex problems and / or conducts moderately complex analyses Translates concepts into practice Assesses and interprets customer needs and requirements Identifies solutions to non sta

Take ownership and responsibility for the design and development of all aspects of manual and automated test approach and strategy. Author and execute the Test Suite of manual and automated test scenarios with traceability to requirements to validate the application. Collaborate with business team members to review and clarify requirements and acceptance criteria for all

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 equitable. Ready to make a difference? Join us to start Caring. Conne

Manages ongoing relationships and service delivery to clients for one or more accounts Acts as outward facing, dedicated resource for assigned accounts, typically with direct client contact (not call center) and large or complex accounts Works closely with Sales Leads on renewals and upselling, but incumbents do not have specific sales goal accountability or primary respo

Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs) Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems Own problem t

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) Validate that cases/requests for services require additional research Identify and utilize appropriate resources to conduct non clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources) Prioritize cases based on ap

Interpret and analyze claims, capitation, membership data, and recommend best approaches in support of underwriting, actuarial and utilization analyses Lead projects to completion by contributing to database creation, statistical modeling and financial reports Performs complex data validation and conceptual analyses. Create and update automated processes within client dat

Develop, lead and execute category management strategies, conduct sourcing / RFX events, manage suppliers and conduct financial analysis Draft, Review, and lead negotiations of third party supplier contracts, including Master Services Agreements (MSAs), Statements of Work (SOWs), Non Disclosure Agreements (NDAs) and amendments in cooperation with legal, internal stakehold

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, c

Perform clinical assessment of healthcare services provided to our members for appropriateness Understand relevant state and federal grievance and peer review requirements and accreditation standards applicable for processes supported Receives cases from the QIS non clinical team and reviews them against required clinical information, assessing for appropriateness and con

Investigate medium to highly complex cases of fraud, waste, and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case information in the Special Investigations Unit's (SIU's) case t

Key Agent/Agency Performance Agent Development Mentor, coach and engage key agents/agencies through ongoing business and strategy planning. This includes identifying sales opportunities, product positioning, UHC tools, UHC value proposition, compliance, and market education Onboarding Reach out to new agents identified by the PHD to share UHC learning, growth tools and va

Sort and file patient demographic forms (may include lifting up to 30 lbs.) Locate and retrieve patient demographic forms when requested. Cross train and work in all processes when needed Other duties as assigned Repetitive movements including sit, stand, kneel, reach You'll be rewarded and recognized for your performance in an environment that will challenge you and give

Respond to and resolve on the first call, customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence Educate customers about the fundamentals and benefits of consumer driven health care, guiding them on topics such as selecting the best benef