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 start Caring. Connecting. Growing together.

Primary Responsibilities:

• Support Optum medical Claims Editing System (CES) for AMS clients
• Partner with Client Leader to establish and strategize how to achieve savings targets
• Identify, research, develop, and size, new prepayment editing opportunities for use in Claims Editing System (CES) edit application for assigned healthcare payers
• Proactively review profiling system rules, using coding, policy, reimbursement, clinical, and claims background to determine which rules can be presented to the payer for new medical cost savings opportunities
• Present new edit concepts to clients during Governance meetings, effectively explaining the rule’s intent, support, anticipated exposure, and influencing the client to adopt the rule
• Execute the ‘Rule Approval’ process
• Generate innovative editing ideas that can be scaled across the organization
• Stay current on client configuration and new CES functionality in order to recommend the most effective rule design
• Conduct root cause analysis, including investigation into Knowledge Base updates, LCD updates, and rule logic defects, to recognize and remediate escalated issues
• Interpret complex reimbursement language, policies, and methodologies
• Define, create and maintain rule requirements
• Acquire and maintain working knowledge of multiple platform specific knowledge, customer customizations, databases, file systems and architecture that support the CES application
• Review quarterly Knowledge Base release to determine custom rule impact and maintenance needs
• Building out non-proprietary and proprietary rule library: proactively share information with internal client teams
• Present and evaluate solutions objectively and facilitate conflict resolution
• Evaluate system changes for downstream system and/or organizational impacts
• Build and maintain working relationships with stakeholders
• Facilitate and/or assist with group meetings via Teams and telephonically, providing agendas and meeting minutes
• Identify new opportunities to improve processes, customer relationships, while increasing our value to our client
• Serve as a mentor to new Business Analysts, and routinely identify, develop, and share best practice experience with peers
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• 3+ years of Healthcare Industry experience (Healthcare reimbursement, claims adjudication, procedure/diagnosis coding knowledge)
• 3+ years of Medicare/Medicaid policy guideline experience
• 3+ years of experience performing Analysis and interpretation of business needs around client payment policies and translate into Business Requirements
• 3+ years of proven ability to interpret technical requirements and business requirements while coordinating with technical staff to help drive solutions for our customers
• 3+ years of proven ability to translate highly complex detailed clinical/technical solution concepts and articulate to technical and non-technical audiences
• 3+ years of experience interfacing with Clients
• 1+ years of experience interfacing at the Executive level
• Proficient with MS Office Applications

Preferred Qualifications:

• Bachelor’s Degree
• Undergraduate degree
• Experience with CES, Claims Manager
• Content Manager experience
• Business Analyst software support experience
• Training experience
• Medical Coding experience or certified medical coder (AHIMA or CPC)
• SQL or Oracle query experience

Soft Skills:

• Solid analytical and troubleshooting skills
• Proven excellent interpersonal, written, and verbal communication skills
• Ability to manage multiple priorities and execute deliverables on time
• Demonstrated outstanding time management skills
• Ability to shift priorities quickly, handling multiple tasks and competing priorities
• Proven highly motivated and innovative, with the ability to work as part of a high-performance team as well as independently
• Demonstrated competency in large-scale organizations within a matrix environment

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.