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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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Senior Business Analyst Consultant CA Payment Integrity will serve as the primary business owner coordinating with the Market, Finance, Product, Medical Directors and Healthcare Economics to identify and implement payment integrity opportunities. The BA Consultant will also work closely with Optum Insight and external vendors as well as our national affordability team and Optum Care payment integrity operations teams. The focus is on ideation and implementation of incremental opportunities. The position will be responsible for deploying a PI operating model which will encompass the following activities:

• Delivering requirements for building operational dashboard reporting on existing programs

• Identify pipeline of program gaps and create roadmap for implementation

• Creating business case to influence market partners and stakeholders to prioritize and deploy new edits, vendors and programs

• Producing standardized savings reporting aligned with HCE approved methodologies across multiple CDO’s

• Reporting performance to various stakeholders

• Holding PI vendors accountable for product performance and implementation timelines

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

Primary Responsibilities:

Become proficient in the local California regulatory, compliance and network contracting and claims processing areas in order to successfully identify and deploy payment integrity programs

• Work across Optum Care entities to develop and implement effective/strategic payment integrity solutions through research and analysis of data and local business processes

• Provide market facing support

• Lead program management for all CA payment integrity services

• Establish strong matrixed relationships with internal stakeholders (including claims operations, network management, medical management)

• Drive short- and long-term strategic business activities across the pillars of Optum Care Payment Integrity

• Claims Editing System - Professional and Facility Rule Sets

• Claims Cost Management - Itemized Bill Review, High Dollar Claims, 30 Day Readmissions, Predictive Analytics

• Audit and Recovery Operations - Focused Claim Review, Credit Balance, Operations Recovery, Waste and Error Post Payment Activities

• Premium Audit Services - DRG Coding and Compliance, Outpatient Facility, Hospital Bill Audit, Inpatient Pricing Tools

• Fraud and Abuse - Establish standardized process for CA CDOs for submissions

• Coordination of Benefits & Subrogation

• Drive consistent and standardized reporting across CA CDOs

• Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance

• Ensure all operational metrics are met

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.

Required Qualifications:

• 5+ years of experience in the health care industry

• 5+ years of experience working within MA, Medicaid and/or commercial lines of business

• Experience with product/vendor implementations

• Experience with end-to-end process ownership for payment integrity program

• Experience in forecasting and budget management

• Experience developing and managing operational metrics

• Payment integrity operations experience: prepayment and/or post-payment processes

• Vendor management experience

• Proficiency in various claims payment methodologies; to include capitation, fee-for-service, DRG, percent-of-charge, and OPPS

• Proficiency using Microsoft Office: Word, Excel (data analysis, sorting/filtering, pivot tables), PowerPoint (prepare formal presentations and training), Visio (develop workflow processes)

• Demonstrated ability to gather and analyze information from multiple sources and use to form a cohesive and comprehensive recommendation or problem solution

• Proven solid consulting and influencing skills; proven results; ability to identify root causes and drive solutions

• Proven high degree of interpersonal and relationship building skills to engage client

• Proven ability to manage competing priorities, make decisions, and effectively execute across a large, global fast-paced organization

• Proven ability to identify, implement, and report opportunities to improve processes, procedures, systems

• Proven ability to develop solid partnership with matrixed partners and stakeholders

Preferred Qualifications:

• 1 or more of the following certifications: CPC, CPCO, AHFI, HCAFA, CFE

• Experience interpreting provider contractual agreements

• Experience managing a comprehensive portfolio of programs

• Experience with California health plan operations

• Proficiency in performing financial analysis/audit

• Comfortable with PMPM calculations and financial goal accountability

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington, Washington, D.C. Residents Only: The salary range for this role is $104,700 to $190,400 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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.