Job Description

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.

We have a position open for a Business Analyst to support the Optum Application Managed Services (AMS) Team. The AMS team engages in long term commitments and partnerships.

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 client's 'Ecosystem'. AMS provides services that will help provide long term benefit for the client, not only direct savings, and increased revenue but also savings in process, manual effort, and other operational areas.

The Business Analyst role requires a highly flexible and adaptable analyst with the ability to handle periods of stress and/or heavy workloads. Solid experience as a Business Analyst or similar role is required, along with demonstrated experience with healthcare claims, or Medical /Drug/ reimbursement policies. The BA must have the ability to not only facilitate meetings but also negotiate and drive effective solutions by proactively review profiling system rules, using coding, policy, reimbursement, clinical, and claims background to determine which rules can be presented to the payer for new medical cost savings opportunities as well as generate innovate editing ideas that can be scaled across organizations. This position requires solid 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 BA. Additionally, the role requires the BA to become a Subject Matter Expert and provide end user training on the functionalized policies. The BA primarily works independently, however is also expected to work collaboratively across teams and the organization to support our client's needs and meet their affordability and saving's targets.

Positions in this function create and deliver high quality system solutions for our applications, products and services across all technology functions. They consult with users and technology specialists to define business processes and the information systems for supporting those processes. Individuals in these roles may perform analysis and also serve as business liaisons to understand and refine business requirements. They provide technical support in developing systems that are cost effective and meet users' requirements. This function works to create systems that work together in a cohesive manner, enforcing standards and methods consistently across the enterprise. Roles may support both current system improvements and maintenance along with new system development.

Primary Responsibilities:

• Support Optum medical Claims Editing System (CES) for AMS clients
• Partner with Client Leader to establish and strategize how to achieve savings targets
• Identify, research, develop, and size, new prepayment editing opportunities for use in Claims Editing System (CES) edit application for assigned healthcare payers
• Proactively review profiling system rules, using coding, policy, reimbursement, clinical, and claims background to determine which rules can be presented to the payer for new medical cost savings opportunities
• Present new edit concepts to clients during Governance meetings, effectively explaining the rule's intent, support, anticipated exposure, and influencing the client to adopt the rule
• Execute the 'Rule Approval' process
• Generate innovative editing ideas that can be scaled across the organization
• Stay current on client configuration and new CES functionality in order to recommend the most effective rule design
• Conduct root cause analysis, including investigation into Knowledge Base updates, LCD updates, and rule logic defects, to recognize and remediate escalated issues
• Interpret complex reimbursement language, policies, and methodologies
• Define, create and maintain rule requirements
• Acquire and maintain working knowledge of multiple platform specific knowledge, customer customizations, databases, file systems and architecture that support the CES application
• Review quarterly Knowledge Base release to determine custom rule impact and maintenance needs
• Building out non-proprietary and proprietary rule library: proactively share information with internal client teams
• Present and evaluate solutions objectively and facilitate conflict resolution
• Evaluate system changes for downstream system and/or organizational impacts
• Build and maintain working relationships with stakeholders
• Facilitate and/or assist with group meetings via Teams and telephonically, providing agendas and meeting minutes
• Identify new opportunities to improve processes, customer relationships, while increasing our value to our client
• Serve as a mentor to new Business Analysts, and routinely identify, develop, and share best practice experience with peers
• Analyzes and investigates
• Provides explanations and interpretations within area of expertise
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regard to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• 3+ years of Healthcare Industry experience (Healthcare reimbursement, claims adjudication, procedure/diagnosis coding knowledge)
• 3+ years of Medicare/Medicaid policy guideline experience
• 3+ years of experience performing Analysis and interpretation of business needs around client payment policies and translate into Business Requirements
• 3+ years of proven ability to interpret technical requirements and business requirements while coordinating with technical staff to help drive solutions for our customers
• 3+ years of proven ability to translate highly complex detailed clinical/technical solution concepts and articulate to technical and non-technical audiences
• 3+ years of experience interfacing with Clients
• 1+ years of experience interfacing at the Executive level
• Proficient with MS Office Applications

Preferred Qualifications:

• Bachelor's Degree
• Experience with CES, Claims Manager
• Content Manager experience
• Business Analyst software support experience
• Training experience
• Medical Coding experience or certified medical coder (AHIMA or CPC)
• SQL or Oracle query experience

Soft Skills:

• Solid analytical and troubleshooting skills
• 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
• Demonstrated competency in large-scale organizations within a matrix environment

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.