1+ months

Claims Business Process Consultant SR - Telecommute

MN Work Remotely
  • Job Code

Welcome to one of the toughest and most fulfilling ways to help people, including yourself. We offer the latest tools, most intensive training program in the industry and nearly limitless opportunities for advancement. Join us and start doing your life's best work.(sm)

Our claims operations, including our Senior Clinical Claims Business Process Consultants, are the focal point of handling information about services patients receive and the way those services get paid. It's complex, detailed work. It's fast paced challenge. It's a job that calls on you to be thoughtful, resourceful, team-driven and customer-focused. To put it mildly, there is never a dull moment.


Positions in this function are responsible for all related aspects of claim system processes and claim business rules. Includes claims systems utilization, capacity analyses/planning and reporting. Includes claims-related business and systems analysis. Ensures data integrity, data security and process optimization.

*Employees in jobs labeled with SCA must support a government Service Contract Act (SCA) agreement.

  • Reviews the work of others
  • Develops innovative approaches
  • Sought out as expert
  • Serves as a leader/ mentor

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

Primary Responsibilities:

  • Responsible for key processes and procedures that support the testing and operational readiness of new concepts which includes
    • Analysis, planning and assisting with all levels of operational readiness and subsequent deployment of new analytic concepts.
    • Vetting initial ideas with outside partners to develop sound concepts.
    • Recommend opportunities to -shift left- thus reducing provider and member abrasion
  • Ensures concept adherence to state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information
  • Conduct claims systems utilization, capacity analysis/planning and reporting, and claims-related business and systems analysis
  • Responsible for performing clinical coding review on professional and facility post-pay and pre-pay claims. Reviews applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with over billing patterns
  • Support test cases in a case tracking system by managing medical records and ensuring high quality review completed within established TAT
  • Performs clinical consultations, acting as subject matter expert, including but not limited to new concept types (professional and facility), concept revisions, analytic interpretation, data review, clinical coding expertise, training, clinical and operational consultation
  • Ensure data integrity, data security and process optimization
  • Serve as our internal Regulatory Affairs' point of contact
  • Partner with functional area leaders and SMEs to determine impact and solutions
  • Implement Claim ops solutions to meet regulatory requirements
  • Participates in meetings with internal partners, Operations and Analytics, which may involve sharing expertise and presenting clinical findings with regard to individual concept test findings
  • Lead Claim Ops market conduct or financial exam activity, corrective action plans responses and restitution projects
  • Remediate gaps in existing production processes that do not meet regulatory requirements
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.



Posted: 2020-09-15 Expires: 2020-11-14

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Claims Business Process Consultant SR - Telecommute

UnitedHealth Group

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