Manager, Pre-Pay Claim Validation - Remote

UnitedHealth Group; Plymouth (MN); Hybrid; USD 92,000 - 164,000; Full time

Job summary

UnitedHealth Group is seeking a Prepay Claim Validation Clinical Manager to lead a staff of clinical investigators auditing medical records and making pay/deny decisions on claims, while overseeing inventory for 5+ clients.

The role emphasizes leadership, process improvement, and collaboration across matrix partners, with remote work flexibility within the U.S. and in-office days in the Minneapolis area.

Qualifications

• Active nursing credential or certified coder.
• 3+ years of management experience
• 3+ years Payment Integrity FWAE Clinical Team and Process experience
• 2+ years of human resource policies and procedures experience
• 2+ years managing in a production-based environment
• 2+ years working in a matrix-driven organization
• 2+ years of experience in supporting clients with varying requirements
• 2+ years of experience in interpretation of data trends and driving solutions
• Preferred: ICD 10/ICD 9 coder, RN/LPN, CMS experience
• Proficient in MS Office with multiple systems experience
• Ability to adapt in changing environments and strong communication skills
• Strong analytical, problem-solving and decision-making skills

Responsibilities

• Provide collaborative leadership to matrix partners to meet client-savings targets and internal revenue goals
• Provide client-facing support to clients and ongoing operations
• Anticipate Client needs and proactively develop solutions
• Lead client implementation readiness and inventory management controls
• Perform data analysis of staff performance to identify gaps
• Consult with partners on operational impacts and analytics discussions
• Develop staffing models by client and ensure timely, high-quality reviews
• Coordinate with Procurement and partners for vendor resources
• Drive process improvements and training with leads
• Co-lead with offshore partners to achieve high client NPS
• Understand cross-client impacts of changes and balance competing client interests

Skills

Nurse/Coder credentials

Management experience

Data interpretation

Policy/Procedures knowledge

Matrix organization experience

Client-facing support

Leadership and development

Job description

Improve the lives of others while Caring. Connecting. Growing together.

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together.

The Prepay Claim Validation Clinical Manager, Fraud, Waste, Abuse and Error Operations will be responsible for leading a staff of clinical professional investigators who are auditing medical records and making pay or denying decisions on claims. Additionally manage the inventory of 5+ Clients.

This person will be responsible for providing leadership and overseeing staff’s day-to-day activities, including timecards, PTO, OT, metrics, inventory management etc. Additionally, they are responsible for employee development, financial savings, revenue / IOI management of their team and adapt departmental plans and priorities to address the business.

This leader is seen as an implementation resource, business process enhancement and short- and long-term strategy for business growth and expansion onshore and globally. This position is also responsible for working with the leads and business analysts to ensure process improvements and P&P’s are accurate and updated. They are responsible for helping with training and working with the leads to ensure the Clinical processes meets the needs of our clients and working with multiple internal and external groups clients around their process and impact of their process on those other groups. This team member will also be responsible for providing operational support in reporting, process improvements, coaching, internal quality, and special projects. This person is expected to have a in depth understanding of their process and be able to speak to it both internally and with external clients. Additionally, they are looked upon to be subject matter expert for their process and must understand how their process fits into the end-to-end process. This position supports, manages and escalates identification of suspected waste & abuse of health insurance claims and ensures claims are accurately handled.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities:

• Provide collaborative leadership to matrix partners including Call Center (PIRT), QA, Analytics (AAL), Ideation and Client Management to ensure client-savings targets and internal revenue and IOI targets are met
• Provide client-facing support to clients and ongoing operations
• Anticipates Client needs and proactively develops solutions to meet them
• Manage and lead all operations client workgroups to ensure successful operational readiness for client implementation (if applicable), while driving issue management resolution and inventory management controls
• Perform data analysis of staff performance to identify performance gaps that require staff development/coaching
• Consult with Matrix Partners to provide operational impacts and readiness in client Analytic Pipeline discussions and deployment including ongoing analysis of algorithm performance (true positive percentages)
• Select, develop and manage staff to maintain appropriate staffing levels to ensure delivery of timely, high quality clinical reviews
• Effectively plan staff responsibilities and manage activities, utilizing staff resources to meet client goals in accordance with established contractual SLAs and other contractual deliverables
• Participate/lead activities that increase employee engagement
• Perform and monitor case volume inventory analysis to proactively identify changes in staffing needs according to client growth goals
• Ensure all productivity and quality SLA metrics are met by operations team and drive strategies to improve efficiency and quality
• Develop and maintain staffing models by client
• Partner with Procurement in managing fulfillment vendor and contracted resources
• Document and drive to resolution operational issues impacting client deliverables
• Co-lead with offshore OGS and OPRO partners in driving low-cost, high-quality and consistent performance to achieve high client NPS
• Understand cross-client impacts of changes and balance competing interests among clients to ensure client targets are achieved

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:

• Nurse or Certified Coder with active credentials
• 3+ years of management experience
• 3+ years Payment Integrity FWAE Clinical Team and Process experience
• 2+ years of human resource policies and procedures experience
• 2+ years managing in a production-based environment
• 2+ years working in a matrix-driven organization
• 2+ years of experience in supporting clients with varying requirements
• 2+ years of experience in Interpretation of data trends and driving solutions

Preferred Qualifications:

• Certified Coder in ICD 10 and ICD 9 or RN/LPN
• CMS experience
• Proficient in MS Office Applications with solid computer skills (e.g. multiple systems experience, keyboarding skills, trouble-shooting IT concerns, etc.)
• Open to change and new information; ability to adapt in changing environments and integrate best practices
• Proven to be highly organized with effective and persuasive communication skills
• Demonstrated solid communication and presentation skills
• Demonstrated solid analytical, problem-solving and decision-making skills required; ability to exercise good judgment

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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 - $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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 help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

UnitedHealth Group is committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need special assistance or accommodation for any part of the application process, please call 1-866-566-8715 to be connected to Recruitment Services. Recruitment Services hours of operation are 7 a.m. to 7 p.m. CT, Monday through Friday.

UnitedHealth Group is a registered service mark of UnitedHealth Group, Inc. The UnitedHealth Group name with the dimensional logo, as well as the dimensional logo alone, are both service marks for the UnitedHealth Group, Inc.

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.