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Director, Payment Integrity - Nashville, TN preferred or Telecommute

01/11/2019Call Center
Job Location:
Nashville, TN
Metro Area:
TN - Nashville
Company Name: UnitedHealth Group
Website:  Click to Visit
UnitedHealth Group
If you want to achieve more in your mission of health care, you have to be really smart about the business of health care. Challenge yourself, your peers and our industry by shaping what health care looks like and doing your life's best work.(sm)   This role is required to support Commercial Data Mining managers for large Payer organizations. The director will be responsible for 3 Operations Managers and 4 Individual Contributors.   You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.   Primary Responsibilities: Utilize standard project plan templates to create and/or tailor project plans to specific customers' needs Analyze RFP/contract language and incorporate requirements into project plans Assist internal and/or external business partners with completion of tasks and resolution of issues and problems with program implementation Establish and/or implement internal and/or external service level agreements in order to ensure ability to monitor and measure program performance (e.g., turnaround time; quality; effectiveness) Identify and/or secure resources (e.g., funding; staffing; system security; real estate and/or telecommuting requirements; hardware/software) required to implement programs Review, create, and/or maintain workflows to ensure they are up-to-date and operationally efficient Provide guidance, expertise, and/or assistance to internal and/or external partners (e.g., claims; call center; benefits; clinical) to ensure programs and strategies are implemented and maintained effectively Communicate with and help internal and/or external partners interpret contractual requirements in order to ensure effective problem solution and strategy implementation Provide input to internal and/or external stakeholders (e.g., sales; shared business partners; pre-service vendors; facilities) in order to drive effective business plan and sales strategy development Seek feedback from customers to determine success of overall project management and implementation Monitor project performance against internal and/or external service level agreements Work with internal and/or external partners (e.g., claims; call center) to ensure accurate reports are produced to validate program performance review Ensure performance is tracked accurately utilizing internal tools and processes (e.g., dashboards; scorecards; reports) Request and/or receive relevant performance data from internal partners and review for accuracy Manipulate provided data into applicable tools and reports in order to facilitate performance review and analysis Review consolidated operational performance reports in order to determine overall effectiveness, make necessary changes, and identify opportunities for new programs or program consolidation or expansion Incorporate operations program performance information into strategic and business planning Delegate post-implementation tasks to appropriate stakeholders to fulfill RFP/contractual agreements Analyze operational performance on relevant criteria (e.g., targeted financial metrics; quality indicators; performance guarantees and/or incentives) Build and demonstrate an understanding of relevant business areas' leadership, structure, responsibilities, and work flow Provide standard performance reports (e.g., scorecards) to update relevant internal and/or external stakeholders on the status of work projects Conduct regular meetings (e.g., JOCs; QBRs) with relevant internal and/or external stakeholders to review and discuss updates and outstanding issues (e.g., project implementation readiness; compliance and/or quality audit results; out-of-compliance issues; staffing issues) Develop corrective action plans to address and/or resolve relevant internal and/or external stakeholders' concerns or issues regarding operational issues Conduct deep dive program reviews with relevant internal and/or external stakeholders to identify opportunities for continuous improvement Ensure relevant internal and/or external stakeholders (e.g., vendors; providers; leased network) are provided with correct and/or updated processes, programs, and/or policies (e.g., fee schedules) Partner with relevant internal and/or external stakeholders to develop and/or review potential operational strategies, programs, and plans (e.g., affordability initiatives; quality programs; projected resource needs) Demonstrate understanding of and adhere to relevant policies, procedures, and regulations Stay abreast of changes and/or updates in relevant policies, procedures, and regulations Train and educate internal stakeholders on relevant policies and procedures Communicate and coordinate with and/or help internal and/or external partners interpret contractual requirements in order to ensure compliance with contractual and regulatory stipulations Provide input into, develop, and/or modify policies and procedures Ensure staff utilizes relevant websites required in order to obtain up-to-date policies, guidelines, procedures, and regulations Track attendance on training for required policies, procedures, and regulations Monitor and/or report on-going compliance and related outcomes (e.g., claim denials; complaints; clinical metrics) to relevant internal and/or external stakeholders (e.g., regulatory agencies; customers; vendors) Utilize stakeholder input to help shape and implement continuous improvement in operational quality and financial performance (e.g., encourages participation in Six Sigma projects) Ensure internal partners and/or external vendors adhere to business and contractual agreements Conduct end-to-end testing of applicable processes, tools, procedures, and systems platforms to validate adherence to RFP/contract requirements Ensure that business continuity/emergency response plans are reviewed and tested regularly, up-to-date, and can be readily executed Utilize relevant systems and tools to identify and/or test opportunities for efficiency improvements (e.g., parallel variable testing) Demonstrate understanding of budgeting and forecasting tools, terminology, and processes Analyze budget performance and variances throughout the fiscal year, and recommend and/or make necessary adjustments and corrections Work with relevant internal partners (e.g., Finance; Underwriting) to identify resource requirements and/or create budgets and forecasts Review and assign projects/initiatives based on resource capacity, capability, and expertise


Required Qualifications: 7+ years of Data Mining management experience; Relevant experience should include first-hand knowledge of Coordination of Benefits, Contractual compliance, Retro termination of benefits, Itemized Bill Review, DRG Audits, Stop Loss Audits, Implant Audits and multiple payment on a service scenarios 2+ years of experience auditing non clinical and/or clinical claims Experiencing analyzing large data sets to determine trends / patterns Experience reading and interpreting provider contracts, fee schedules, and claim payment policies Experience navigating claim and member adjudication systems Experience identifying, researching and developing new overpayment concepts Experience interacting with and presenting to clients in the form of strategic business reviews Experience implementing new business (e.g. defining scope, building workflows, establishing expectations, etc.) Prior experience managing a team Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)   *All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy 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.   Job Keywords: Payment Integrity, Data Mining, Coordination of Benefits , Contractual compliance, Retro termination of benefits, Itemized Bill Review, DRG Audits, Stop Loss Audits, Implant, Nashville, TN
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