UnitedHealth Group Clinical Data Consultant, Custom Edit Concept Development (CECD) - Eden Prairie, MN or Telecommute in Eden Prairie, Minnesota

We have a position open for a Clinical Consultant to support the Optum Application Managed Services (AMS) Team as a member of the Custom Edit Concept development team (CECD). The AMS team engages in long term commitments and partnerships with large payer clients.

AMS provides full service operation to our clients with a proactive approach to business communication, growth, and problem resolution. The AMS team partners with health plan clients to become an extension of their organization. The highly seasoned staff is dedicated to managing Claims Edit System (CES) as well as looking at where CES fits in the clients “Ecosystem." AMS provides services that will help provide long term benefit for the client, not only in direct savings and increased revenue, but also savings in process, manual effort, and other operational areas. CECD supports the AMS team by finding custom editing opportunities for large payer clients based on findings from the client’s claims experience to enhance customer value derived from CES.

The Clinical Consultant role requires a highly flexible and adaptable consultant with the ability to handle periods of stress and/or heavy workloads. Solid experience as a consultant or similar role is required, along with demonstrated experience with healthcare claims, or Medical / Drug / Reimbursement policies. The Clinical Consultant must have the ability to not only facilitate meetings but also negotiate and drive effective solutions, while producing detailed business requirements and other required supporting materials. This position requires strong communication skills with ability to liaison between technical and non-technical personnel. The ability to adeptly navigate ever changing priorities is also a key skill of the Clinical Consultant. The Clinical Consultant must work independently, however is primary responsible for working collaboratively across teams and the organization to support our client's needs and meet their affordability and saving’s targets.

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

Primary Responsibilities:

  • Identify savings initiatives that drive specific and measurable results for assigned clients, providing timely and meaningful client updates

  • Analyze client specific data and detect, develop, and deploy custom claim edits in the client CES library

  • Establish strong matrixed relationships with internal and external stakeholders to define, align, and deliver payment integrity initiatives in support of assigned clients

  • Create effective concept documents and present the documents to clients for approval

  • Influence senior leadership to adopt new ideas, approaches, and/or products

  • Recommend changes to current product development procedures based on market research and new trends

  • Identify new opportunities to improve processes, customer relationships, while increasing our value to our client

  • Build out non-proprietary and proprietary rule library, and proactively share information with internal client teams

  • Acquire and maintain working knowledge of multiple platform specific knowledge, customer customizations, databases, file systems, and architecture that support the CES application

  • Execute small to large projects from inception through implementation

Required Qualifications:

  • Undergraduate degree or 5+ years of equivalent experience

  • Previous healthcare industry experience (healthcare reimbursement, claims adjudication, procedure / diagnosis coding knowledge, code editing experience across all code edit categories)

  • 3+ years of Medicare / Medicaid policy guideline experience

  • Demonstrated experience translating payment / reimbursement policy into effective code edits

  • Demonstrated experience performing analysis and interpretation of business needs around client payment policies

  • Advanced proficiency with MS Excel

  • Ability to query within a database (SAS, SQL, Access, etc.)

  • Ability to translate highly complex detailed clinical / technical solution concepts and articulate to technical and non-technical audiences

  • Experience interfacing with clients

Preferred Qualifications:

  • Previous SQL querying experience

  • Previous experience with CES or other similar claim edit products

  • Previous Content Manager experience

  • Analyst software support experience

  • Medical Coding experience or certified medical coder (AHIMA or CPC)

  • Nursing or other clinical experience

  • Experience in healthcare fraud, waste, and abuse investigations at a health plan or government agency

  • Excellent interpersonal, written, and verbal communication skills

  • Ability to manage multiple priorities and execute deliverables on time

  • Demonstrated outstanding time management skills

  • Ability to shift priorities quickly, handling multiple tasks and competing priorities

  • Highly motivated and innovative, with the ability to work as part of a high performance team as well as independently

  • Comfortable interfacing at the executive level

  • Comfortable navigating a large-scale organization within a matrix environment

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care 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: healthcare, health care, claims, claims edit system, CES, reimbursement, coding, payment policy, cost savings, fraud, waste, abuse, FWAE, investigation, research, Excel, SQL, database, querying, client management, Eden Prairie, MN, Minnesota, telecommute, remote, work from home