Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements Engage with requesting providers as needed in peer to peer discussions Be knowledgeable in

Partner with community providers of peer support to expand the network and ensure quality services are available for our members Educate by creating new curriculum specific to state need and facilitate community trainings Model the principles of recovery and provide member perspective to our CM, UM, Network, Product and Affordability partners Advocate for a recovery persp

Works to ensure that internal processes are executed, especially related to intersegment responsibilities, for fraud, waste, and abuse (FWA) vendors' instances of health care FWA by medical profession or insured member Acts as FWA subject matter expert for Federal and local FWA regulations and subsequent regulatory policy and process implementation Keeping apprised of cur

Provide an exceptional customer service experience when responding to and resolving customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence Research complex issues (such as Medical, Dental, Flex Spending, Pharmacy, etc.) across multiple da

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, c

Test Data Provision & Masking Operation Test data need & masking analysis ( Data structure, SQL queries) Working with Informatica tool to configure & invoke Data Copy and Masking jobs and maintain Gold Copy Maintenance of TDM Portal using UNIX scripting, Java Spring boot and Angular You'll be rewarded and recognized for your performance in an environment that will challen

Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs) Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems Own problem t

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Recruits, hires, and manages performance of staff (2 3 employees) providing ongoing feedback, conducting regularly scheduled 1 1s and facilitating the performance management process in a timely manner Leads team pipeline generation, using a curated set of UHG sales tools and prospecting persistence to identify and validate opportunities Guides team members to attain month

With guidance from audit management or audit lead, execute internal audits including audit planning, detailing control procedures, and the related testing and reporting in accordance with professional and departmental standards including financial (Sarbanes Oxley testing) and operational projects Prepare clear, accurate, and complete workpapers in accordance with departme

Assess complaints of alleged misconduct received within the Company Investigate low to medium complex cases of fraud, waste and abuse Detect fraudulent activity by members, providers, employees and other parties against the Company Develop and deploy the most effective and efficient investigative strategy for each investigation Maintain accurate, current and thorough case

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, c

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. Connect

Full oversight of the specialty sale to achieve health plan market sales goals and maintain profitability Advocate for specialty voluntary products to support increase in enrollment and size of sale and negotiate based on broker/customer feedback with underwriting; leveraging rate bank, product discount programs and packaged savings to leverage the best value to the custo

Work with CICD frameworks to develop data solutions to support performing analysis, interpreting results, creating actionable insights, and presenting recommendations for use across the company Use business intelligence, data visualization, query, analytic and statistical software to build solutions, perform analysis and interpret data Partnering with stakeholders to unde