Provider Outreach - Data Mining

UnitedHealth Group

About The Position

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. This role performs Clinical Procedure Coding research and outbound calling activities related to Data Mining programs. The successful candidate will review all types of medical claim payments from a research perspective in support of auditors and new outreach ideation. This role requires strong interpersonal skills combined with deep Clinical Procedure Coding, billing and claim platform knowledge to support outbound calling activities. These outbound calling activities relate to a varied and specialized set of unlikely billing scenarios. The successful candidate should have prior experience within the U.S. HealthCare industry with specific proficiency within reimbursement policy, provider contracts and clinical coding. Expertise with regard to navigating and understanding UHG core claims platforms (UNET, COSMOS, CSP, NICE etc.) is an advantage for this role. Prior experience within Payment Integrity, Network Management or Claims Operations is a distinct advantage. All the above is undertaken in collaboration with various matrix business partners.

Requirements

2+ years of health care outreach experience designing call strategies and conducting calls to providers
2+ years of health care experience working with claims data and / or medical codes
2+ years of experience researching medical claims information both internal and external
1+ years of experience working with processing and reviewing medical claims platforms
Experience analyzing claims to determine trends / patterns
Experience reading and interpreting medical bills and records, provider contracts, fee schedules, and claim payment policies
Professional proficiency in both English and Spanish (bilingual)
Computer proficiency in Microsoft Office including Word (create documents), Excel (data entry) and Outlook (send email / calendar utilization)

Nice To Haves

Experience with Pharmacy billing

Responsibilities

Obtain all available data relevant to determine suitability and conduct Outreach call
Work with payers/providers to review claim information and identify issues related to payment accuracy
Design and implement appropriate outreach calling strategies specific to providers and outreach scenarios to determine advantageous call success rates
Assesses and interprets customer needs and requirements
Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
Use pertinent data and facts to ideate, identify and solve a range of problems within area of expertise
Ability to communicate the outcome of this research in a manner suitable for the intended audience
Identify potential concepts for retrospective and prospective savings through individual ideation and from several perspectives such as correct billing, clinical procedure coding, network contracting, policy reimbursement, medical documentation requirements, industry and federal guidelines
Advise auditors on billing and coding guidelines to identify potential overpayment scenarios
Document and communicate outcomes of outreach reviews to applicable stakeholders