At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.
As a Tribal Operations Provider Claims Resolution Specialist, you will manage outcomes by analyzing, reviewing, forecasting, trending and then presenting information for operational and business planning, all while adapting to change quickly. This position reviews State requirements to ensure they are apprised of the requirements for Personal Care Workers (PCW). This position will manage and monitor Exclusive Tribal contracts initiated with Pueblos, Tribes and Navajo Nation. The Tribal contracts will include extended benefits available to tribal members including but not limited to cultural services. The position supports the PCW provider community by developing, enhancing, and maintaining operational information and managing outcomes. This position will work with Tribal Executive Direct to develop and implement effective/strategic business solutions through research and analysis of data, business processes and distribution of required reporting.
This position is full - time (40 hours / week) Monday - Friday. Employees are required to have flexibility to work any of our 8 - hour shift schedules during our normal business hours of 8am to 5pm. It may be necessary, given the business need, to work occasional overtime. This position is a field - based position with a home - based office. You will work from home when not in the field.
If you are a resident in New Mexico, you will have the flexibility to work remotely* as you take on some tough challenges.
- Analyze and interpret claims data to identify trends, patterns and opportunities for the internal business, State of NM, and Tribal contracts
- Present and distribute reporting analysis and interpretation to appropriate provider and internal audiences
- Produce, publish, and distribute reports relating to claims and the accuracy of claims payment
- Monitor, distribute, and maintain reporting for claims paid to Tribal Contracts
- Practice cultural sensitivity and cultural competence in communication with tribal clients
- Partner with external client, internal Provider, and claim team (community, providers, internal staff)
- Knowledge and continued learning of community cultures and values
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.
Years of post-high school education can be substituted/is equivalent to years of experience
- 2+ years of experience in a customer service role working directly with providers and/or members
- 2+ years of experience with claims processing
- Experience with Tribal provider claim payment and facilities
- Experience in analysis of business process and providing an evaluation, and/or process improvement recommendations
- Experience with PC-based software programs and automated database management systems (Excel, PowerPoint, etc.)
- Designated workspace inside the home with access to high - speed internet availability
- Currently reside in New Mexico
- Willing or ability to travel locally up to 25% of the time
- 2+ years of experience with claims processing in Facets
- 1+ years of experience with project methodology (requirements, design, development, test and implementation)
- Experience with Tribal provider claim payment and facilities (IHS, I/T/U, FQHC, Tribal Providers)
- Experience working in Managed Care
- Articulate and able to communicate with peers internal and external to the organization
- Knowledge of Medicaid and / or Medicare population
- Soft Skills: - Proven ability to work in a fast-paced environment on multiple projects with tight deadlines while paying close attention to the details of all the deliverables
- Proven ability to speak one or more Native American languages
- Proven ability to be accountable for all work with minimal oversight
- Proven keen judgment and collaborative problem-solving skills
- Proven excellent time management, organizational, and prioritization skills and ability to balance multiple priorities
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
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.
- Business Planning
- Business Process Improvement
- Business Processes
- Claim Processing
- Customer Service