Director of Claim Operations – Telecommute

UnitedHealth Group
April 6, 2021
Atlanta, GA
Job Type


Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

OptumCare is succeeding at helping people live healthier lives by taking a different approach to health care. OptumCare uses a commonsense approach, focused on avoiding jargon, finding more efficient ways to operate, and providing great, in-the-moment service. We provide that service by making sure serving our patients and providers is always the first priority. Each department works from the same central idea: “How does this affect the service we provide?”  Because of the extreme commitment to service, OPTUMCARE focuses on recruiting passionate employees who will take advantage of being empowered to provide the highest level of service at each and every step. 

OptumCare is a network of health care providers in local markets whose mission is to help providers deliver the most effective and compassionate care to each patient they serve. OptumCare’s primary focus is on doing the right things for patients, physicians, and the community. It uses an innovative service model focused on measuring what matters and increasing efficiency and performance while providing the highest level of customer service. This model allows OPTUMCARE to make a difference each day by delivering highly personal, customized care management to its patients.

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

On the one hand, no industry is moving faster than health care. On the other, no organization is better positioned to lead health care forward than Optum and UnitedHealth Group. That’s what makes this opportunity so applause worthy. We have hundreds of business verticals across our matrixed organizations that are bringing thousands of new ideas, services and products to the marketplace every year. Our goal is simple. Use data and technology to help drive change and make the health care system work better for everyone. When you join us as Director of Claim Operations, you'll be engaged in a complex business model that is highly adaptable to build solutions that meet their customer needs in a competitive and effective way.

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

Primary Responsibilities:

This role will challenge your ability to work in a complex environment of claim processing operations where we are expanding capabilities rapidly to meet customer requirements and grow the business. You’ll need flexibility, agility and the ability to adapt to change while maintaining strong relationships with stakeholders in a highly cross-matrixed environment.

  • Provide leadership to and is accountable for the claim operation performance and direction through multiple layers of management and senior level professional staff.
  • Scope of responsibility across multiple regions / sites and markets multiple markets.

Lead claim processing operation end to end:

  • Achieve market SLAs through operational discipline, implementing process controls and delivering end to end quality
  • Demonstrate knowledge of applicable claims processes (e.g., end-to-end claims cycle, auto-adjudication, manual work processes, payment methodologies, rework/adjustment processes)
  • Leverage forecasting systems/processes to identify applicable problems / issues / opportunities (e.g., inventory, inflow, overtime), and analyze historical data / trends to drive inventory inflow and resource planning
  • Identify and resolve claims processing errors / issues and trends, as needed (e.g., related to system configuration, network, eligibility, data accuracy, vendor-related, provider).  Collaborate with internal business partners to resolve claims errors / issues (e.g., Subject Matter Experts, Network Management, IT / systems staff, Compliance, vendor management teams, contract teams)
  • Support growth through scalable capabilities across technology, operations, health plan and market

Lead and develop team

  • Support growth through talent management, developing future leaders and team talent for advanced positions within claim operations and across partner capabilities teams
  • Enable front line staff with tools, training and development paths.  Empower through delegation and culture of innovation and continuous improvement.  Manage accountability for performance of teams
  • Lead culture of inclusivity, equity and purpose-driven work

Maintain strong relationships with business customers

  • Improve stakeholder satisfaction through a “feel local” operation, timely end to end issue resolution, proactive communication and reduced defects
  • Communicate the value of our services to applicable audiences, using clear, simple language to ensure understanding
  • Advance innovative capabilities and deliver incremental value to stakeholders

Use Claims Processes and Procedures

  • Apply appropriate processes and procedures to process claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents / certificates)
  • Apply knowledge of applicable laws, regulations and compliance requirements to ensure that claims are processed properly (e.g., HIPAA, PPACA/Health Care Reform, state-specific regulations / grievance procedures, TAT)
  • Use appropriate documentation, reference materials and/or websites to ensure that claims are processed accurately and efficiently (e.g., policy / procedure manuals, knowledge libraries, bulletins, training materials, databases, SharePoint sites, data warehouses)
  • Develop / maintain detailed process documentation to describe solutions / process changes (e.g., solution summary document, process mapping, Policies/Procedures, SOPs)

Demonstrate Knowledge of Products and Services

  • Demonstrate knowledge of applicable product / service offerings, and the value they provide to members and providers.  Keep current on new product/service offerings and the value they provide
  • Demonstrate knowledge of benefit plan provisions (e.g., plan language, coverages, limitations, exclusions) and keep current on changes as they occur

Demonstrate Knowledge of Applicable Laws and Regulations

  • Demonstrate knowledge of applicable legal / compliance requirements, and the penalties associated with non-compliance (e.g., HIPAA, CMS, state regulations, performance guarantees, service level agreements)
  • Maintain awareness of changes to applicable laws and regulations impacting claims business processes (e.g., Healthcare
  • Reform / PPACA, CMS, state regulations)
  • Translate and incorporate changes to laws and regulations for use in applicable business process documents (e.g., process summaries, instructions, procedures)

Identify and analyze claim operations problems/issues/opportunities.  Develop / recommend and implement solutions to improve claims business processes

  • Identify root causes of identified claims processing problems/issues (e.g., root cause analysis, workflow analysis, vendor analysis)
  • Leverage applicable industry standards / benchmarks, and identify opportunities for improvement based on industry standards
  • Partner with applicable stakeholders to drive effective implementation of solutions / process changes (e.g., Claims leadership, Configuration, PDM, Automation, Vendors, Quality, other business partners)
  • Develop appropriate measurement approaches / metrics to evaluate the effectiveness of implemented solutions / process changes (e.g., quality, accuracy, turnaround time, key performance metrics) and/or business targets (e.g., financials, time to pay, performance guarantees)

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:

  • Undergraduate degree or equivalent work experience
  • 10+ years of progressive leadership experience in operations
  • Experience with Trizetto Facets claim adjudication platform
  • Client engagement experience
  • Vendor management experience
  • Experience managing complex business operations/processes - driving efficiencies and scaling for growth, and implementing appropriate operational controls and metrics
  • Experience in rapid growth, multi-stakeholder environment
  • If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained

Preferred Qualifications

  • 5+ years of progressive leadership experience in claim operations
  • Experience with multiple products (Medicare, Medicaid, Duals, Commercial)
  • Experience working across multiple Health Plan payors

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)

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

 *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Colorado Residents Only: The salary range for Colorado residents is $110,200 to $211,700. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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. 

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment

Job Keywords:  Claim Operations, Facets, Claim Capabilities, Business Process, Leadership, Client Implementations, Requirements, Innovation, Automation, Vendor Management, Business Operations, Director of Claim Operations, Director of Claims, Claim Director, Healthcare, Telecommute, Remote, Work from Home

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