General Job Description

Positions in this family support claim processing functions, to include investigations, negotiating settlements, payments, research regarding eligibility, etc.

Job Function Description
Positions in this function are responsible for all related aspects of EDI claim system processes and claim business rules. Includes claims-related business and systems analysis. Ensures data integrity, data security and process optimization.

General Job Profile

• Develops innovative approaches.
• Sought out as subject matter expert.
• Serves as a leader/ mentor.

Job Scope and Guidelines

• Anticipates customer needs and proactively develops solutions to meet them.
• Serves as a key resource on complex and/or critical issues.
• Solves complex problems and develops innovative solutions.
• Performs complex conceptual analyses.
• Forecasts and plans resource requirements.
• May lead functional or segment teams or projects.
• Provides explanations and information to others on complex issues.
• Motivates and inspires other team members.

Functional Competencies

Identify and Analyze Business Requirements and Problems/Issues/Opportunities

• Perform research to identify business requirements (e.g., interviews, observation, focus groups)
• Obtain and validate business requirements from applicable stakeholders (e.g., using health plan documentation, provider manuals, national regulatory lists, etc.)
• Analyze business requirements to determine if existing systems/processes are optimized to achieve those goals, and to identify potential problems/issues/ opportunities
• Leverage applicable industry standards/benchmarks, and identify opportunities for improvement based on industry standards
• Utilize applicable service standards and other key performance metrics to drive identification of potential problems/issues/opportunities (e.g., performance guarantees, service level agreements, state contract requirements)
• Work with business manager to target, prioritize and execute the onboarding and testing of EDI implementations
• Monitor and report day-to-day EDI transactions and interactions of provider/client EDI claims processing
• Responsible for research and resolution of electronic claim issues

Develop/Recommend Solutions/Options to Improve Claims Business Processes

• Develop/recommend solutions to identified claims business process problems/issues
• Identify applicable stakeholders and obtain appropriate approvals/buy-in for recommended process improvements (e.g., leadership, business partners)
• Develop appropriate measurement approaches/metrics to evaluate the effectiveness of recommended solutions/process changes (e.g., financials, time to pay, performance guarantees)
• Perform testing/piloting of electronic data files and ensure effectiveness prior to implementation
• Identify/apply appropriate process implementation methodologies to measure and validate the effectiveness of process changes (e.g., DMAIC)
• Develop/maintain detailed process documentation to describe solutions/process changes (e.g., solution summary document, process mapping) 

Document and Communicate Claims Business Process Information

• Provide ongoing communications/updates to applicable stakeholders on progress/ outcomes of process improvement efforts and projects (e.g., tollgates, leadership presentations, emails)
• Extract claims processing data/information from applicable systems/repositories and provide to appropriate business partners for analysis
• Update process documents to reflect changes in claims business processes
• Provide appropriate documentation to support audit processes (e.g., audit packets)
• On-boarding clients and providers, reporting and project management tasks as assigned

Demonstrate Knowledge of Internal Business Structures and Processes

• Demonstrate knowledge of all applicable business partners/stakeholders involved throughout the claims process (e.g., Operations, Quality, leadership)
• Demonstrate knowledge of financial impact of claims process inefficiencies (e.g., penalties)
• Demonstrate awareness of the impact of claims business processes/changes on other parts of the business (e.g., state-specific configurations vs. global)
• Demonstrate knowledge of applicable quality methodologies/approaches (e.g., Six-Sigma, "Lean" processes)

Demonstrate Knowledge of Applicable Laws and Regulations

• Demonstrate knowledge of applicable legal/compliance requirements, and the penalties associated with non-compliance (e.g., HIPAA, CMS, state regulations, performance guarantees, service level agreements)
• Maintain awareness of changes to applicable laws and regulations impacting claims business processes (e.g., Healthcare Reform/PPACA, CMS, state regulations)
• Translate and incorporate changes to laws and regulations for use in applicable business process documents (e.g., process summaries, instructions, procedures)

Values Based Competencies
1. Integrity Value: Act Ethically

• Comply with Applicable Laws, Regulations and Policies
• Demonstrate Integrity

2. Compassion Value: Focus on Customers

• Identify and Exceed Customer Expectations
• Improve the Customer Experience

3. Relationships Value: Act as a Team Player

•  Collaborate with Others
• Demonstrate Diversity Awareness
• Learn and Develop

4. Relationships Value: Communicate Effectively
Influence Others

• Listen Actively
• Speak and Write Clearly

5. Innovation Value: Support Change and Innovation

• Contribute Innovative Ideas
• Work Effectively in a Changing Environment

6. Performance Value: Make Fact-Based Decisions

• Apply Business Knowledge
• Use Sound Judgment

Training and Skills

• Able to work effectively in a fast-paced, changing environment, contribute innovative ideas
• Self-starter, able to independently drive work
• Inquisitive
• Identify and exceed customer expectations
• Teamwork skills, collaborate with others to learn and develop
• Excellent time management, organizational and prioritization skills, able to effectively balance multiple priorities

Required skills:

• Minimum of 3 - 5 years of experience with electronic data transactions within a matrix organization
• Analytical skills with the ability to interpret data, draw and present quantitative conclusions in a compelling manner across all audiences
• Process improvement, workflow, benchmarking, and/or evaluation processes
• Project coordination experience
• Excellent communication and presentation skills
• Intermediate MS Office and other analytical tools/databases

Preferred skills:

• Undergraduate degree strongly preferred, but not required
• 3+ years of prior experience as a Business Analyst
• Healthcare experience
• Experience with electronic claims data transactions

OptumHealth is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.

OptumHealth 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 health care 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.

At OptumHealth, you will perform within an innovative culture that's focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that's greater than you've ever imagined.

Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.