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. Connecting. Growing together.
The Provider Reimbursement Specialist is responsible for activities associated with developing programs, policies, and strategies to ensure that contracted rates and reimbursement policies are applied accurately for company affiliates. This position analyzes claims, pre and post payment (audit), to ensure contracts and reimbursement policies and procedures are priced accurately. The Provider Reimbursement Specialist reviews claim disputes to verify correct pricing and analyzes claim inquiry data to determine root cause of errors; recommends system changes, training, and process improvements to prevent future errors. May audit repriced claims for internal teams and provide telephone or email reach outs to network representatives to determine contract details. Works with both internal and external customers to identify and resolve complex problems. Assists company affiliates with initial deployment and ongoing support of systems and processes to leverage network rates and policies. Fee schedule and contract maintenance may be included. Position will involve Inventory management and regulatory compliance claim review.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
Research and develop applicable business rules that support product reimbursement methodologies and policies for existing and new business opportunities
Perform post-load quality analysis review on relevant claim platform submissions and provide correction instructions if necessary. Write technical specifications or business requirements that support the development of business applications or enhancements
Perform and/or review user acceptance testing of relevant applications (e.g., support fee schedule; rates; claim editing system; claim pricing system). Write internal operational policies that support global functions
Create and manage detailed work process flows that show critical functions and hand-off between internal and external Departments
Research new opportunities to improve operating efficiencies and/or reduce administrative expenses and provide appropriate recommendations to applicable audiences
Monitor reimbursement practices to ensure policies are being implemented properly and to provide appropriate guidance, training, P&P updates, and education
Facilitate and/or serve as reimbursement subject matter expert in interdepartmental meetings or complex claim reviews to ensure accurate implementation and completion of reimbursement solutions
Request applicable data from reporting areas; perform queries on applicable systems; analyze data (e.g., provider; claims; partner; reimbursement) to ensure accurate reimbursement
Use and interpret data analysis (e.g., provider; claims; ppoONE; reimbursement) to quantify and identify trends and root cause of problems to determine possible corrective actions or system changes
Provide ongoing business direction, support, and justification for approved system enhancements
Work with the appropriate areas to resolve claim issues related to reimbursement policy/iCES editing
Develop and/or deliver educational and communication materials regarding Provider Reimbursement tools, policies, programs, procedures, solutions, and changes to internal and external stakeholders
Provide inventory management direction to internal UHN Teams at UMR
Assist with claim, contract, and file reviews in relation to federal regulatory and compliance
Actively work assigned UHN Team inventory (UHCA ticklers, complex claim analysis, stop loss claims, etc.) and maintain required TAT
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:
4+ years of NDB, ppoONE, iCES and UHC claim pricing knowledge
4+ years of experience analyzing and handling inquiries or escalated issues for UHC priced claims
4+ years of UHC provider contract knowledge
4+ years of experience repricing HCFA and UB claims
4+ years of experience with CPO/CRA team for submitting claim reviews and inquiries
3+ years of knowledge or experience with UMR CPS processes
Preferred Qualifications:
Demonstrate understanding of relevant software (e.g., Word; Excel; PowerPoint; Visio; Desktop Applications)
Demonstrate understanding of end-to-end processes that impact Provider Reimbursement (e.g., provider relations; network contracts; system configurations)
Interpret and apply reimbursement regulations and policies
Demonstrate understanding of different reimbursement methodologies (e.g., DRG; APC; Case Rate; fee for service; capitation)
Demonstrate understanding of contractual agreements in order to provide correct guidance and ensure practices are consistent with standards
Soft Skills:
Solid Interpersonal Skills: ability or desire to learn how to run small group meetings and present in UHC Network meetings
Solid business, written and oral communication skills
Ability to handle a fast-paced environment with pressure based on project deadlines or required performance guarantees
Candidate needs to be organized and detail oriented
Ability to provide team member direction in a positive manner
Application of the UHC Core Values in action: Compassion, Integrity, Performance, Inclusion, Relationships, and Innovation
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The hourly range for this role is $28.03 to $54.95 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
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.
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.
UnitedHealth Group
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