Director Payer Solutions - Remote

UnitedHealth Group • Rancho Cordova, CA

9d • $54 - $93 • Remote

About The Position

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.

You believe data can help reshape the future, and you find yourself loving the thrill of diving into challenging analysis. At UnitedHealth Group, you’ll find an organization that will recognize those talents and have lots of growth potential. Here, you will be empowered, supported, and encouraged to use your analysis expertise to help change the future of health care.
The Director Payer Solutions position is responsible for managing payer escalations, settlements, and contract compliance within the Payer Solutions team. This role works with revenue cycle stakeholders, client executives, and payer leadership to address complex matters and support payer performance.

The Director Payer Solutions provides assistance to the Payer Solutions Team, focusing on customer service for the Client Contracting Team, Client Executives, Client CFOs, and Internal O360 Revenue Cycle Teams. Responsibilities include oversight of Payer Project Escalations for major Managed Care Payers, including JOC Payer Projects, settlements, litigation, arbitration, and bankruptcies. The position involves collaboration across the revenue cycle and requires meetings with Payer Leadership, Contracting, VPs, CFOs, and Revenue Cycle Stakeholders.

You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Requirements

• 5+ years of experience interpreting payer contracts, applying contract terms, analyzing rate schedules (including DRG, APR-DRG, per diem, case rate, and percent-of-charge models) with a solid grasp of claims adjudication processes, root cause denial analysis, and clinical/technical coding practices (ICD-10, CPT, modifiers)
• 5+ years of progressive experience in revenue cycle management with deep expertise in billing, collections, payer disputes, contract interpretation, and denial resolution (Must have a comprehensive understanding of commercial and managed care payer billing guidelines, CMS regulations, and Medicare reimbursement policies)
• 5+ years of Managed Care contractual agreements experience - specifically the demonstrated ability to read, interpret, and apply contract to billing, including payer policies and provider manuals and expertise in government and non-government auditing and reimbursement
• 5+ years of experience in Healthcare Revenue Cycle, including working with Patient Financial Services, Business Office, Insurance claim billing, Collections, Reimbursement, Patient Access, Coding, Denials Management and Payor Appeals with hospitals
• 5+ years of experience analyzing large data sets to identify denial/payer trends, develop baselines, and track improvement and creating presentations demonstrating outcomes and presenting in-person or remotely to executive audiences
• 3+ years of Project Management experience with an understanding of action items, next steps, assignment of tasks, measuring improvement, holding others accountable, documenting processes and practices (process maps, job aids, instructions)
• Expert level knowledge to operationalize payment policies and escalate systemic payer issues with data-driven insights (Qualified candidates must be adept at translating contract language into payment expectations and building workflows to ensure accurate reimbursement in alignment with payer agreements and federal guidelines to meet this requirement)
• Advanced experience with Excel (solid skills with VLOOKUP, Pivot Table, Formulas), PowerPoint, Word, Teams, Outlook with ability to build reports, presentations, spreadsheets, and process maps
• Advanced experience in EFR, Cerner/EDM

Nice To Haves

• Experience or confident ability to learn Microsoft Visio, Microsoft Power BI, SharePoint, O360 PIC reimbursement Tool
• Able/willing to travel to east/west coast approximately 10%25 as business needs dictate

Responsibilities

• Serve as subject matter expert on payer contracts, reimbursement policies, and UB-04 claim guidelines. Subject matter expert with contract language
• Expert in contract interpretation and contract language application to accounts receivable and issue identification.
• Expert in UB-04 claim editor guidelines, timely/appeal guidelines, CMS guidelines, and payer reimbursement processes to ensure accountability and compliance
• Expert in calculating expected reimbursement based on charges billed on UB-04 forms and the negotiated contract between the payer and Dignity Health, applying all terms and considerations, including CMS guidelines and payer policies
• Solid ability to identify and validate poor payer behavior, analyze accounts receivable and applying contract, policy and provider manuals to strengthen rebuttal against payer. Create trending payer projects
• Manage payer escalations, litigation support, bankruptcies, and settlements from start to finish
• Prepare and deliver professional presentations and reports using Excel, Power BI, and PowerPoint
• Collaborate with contracting and finance teams during renewals and audits; provide payer overviews and analytics
• Maintain accurate reporting (DH91, WINs, Executive Committee updates) and facilitate payer learning sessions
• Drive process improvements across the revenue cycle using Six Sigma methodologies
• Support data compilation for arbitration, litigation, and contract negotiations
• Ensure compliance with CMS guidelines and payer policies; escalate unresolved issues per client protocols
• Prepare and present highly professional presentations for Managed Care Payer Leadership, Contracting, VPs, CFOs, Revenue Cycle Stakeholders client CFOs using Microsoft PowerPoint, Power BI, and Excel. Presentation includes organized Pivot Tables summarizing data
• Point of contact for Client Contracting/PSR Team. Field all data requests, reporting asks. Ability to understand the client ask and provide further insight/questions to ensure alignment.
• Run reports from PIC identifying the key data elements needed to quantify AR impact. Submit tickets and work with Optum BIA Reporting Team
• Facilitate start to finish of settlements from data capture, presentation to the client, identification of missing data elements, validation of the data, refresh to the data and analytics. Coordinate the completion of missing data fields in reporting such as policy number, claim numbers and other necessary fields that are not always reportable
• Manage team of JOC Analysts (3-7 Analysts, as needed), facilitate with project management.
• Other functions as required for the Payer Solutions Team

Benefits

• In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees