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Senior Health Plan Reporting Analyst - Warwick, RI

Company: UnitedHealth Group
Location: Los Angeles
Posted on: September 25, 2022

Job Description:

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm) The Health Plan Analyst is responsible for oversight, support and delivery of contractual reporting and attestations. Creating and analysing and presenting reports for the health plan and stakeholders. Prepare for and act as subject matter expert (SME) in response to inquiries and -requests. This includes becoming familiar with regulatory requirements, -processes, and maintaining tools to ensure alignment between them all. Interface with claims, member relations, provider relations, and all other customer support staff in solution of benefit and provider issues. Serve as a key resource on complex and/or critical issue. Analyze escalated claim processing issues and work with internal partners to drive remediation. Prepare, research and attend State fair hearings. - This position must be located in Warwick, RI. - You will work in the Warwick office, visit local providers and work from home as needed. - Primary Responsibilities:

  • Core Medicaid Contractual Reporting Support
    • The Health Plan Analyst will be responsible for timely and accurate delivery of operational reporting and program requirements in accordance with Core Medicaid contract with RI EOHHS
    • Responsibilities include, but are not limited, coordination and production of operational reporting per EOHHS reporting calendar
      • MCO Demographic Policy
      • MCO Change Request (Dis-enrollments)
      • Out of State Fraud Report
      • EOMB fraud, waste, and abuse process oversight
      • In collaboration with the health plan Compliance officer, the operations analyst will support the following processes to ensure accurate and timely delivery of all ad-hoc, monthly, quarterly, and annual operational reporting requirements to EOHHS
        • Reporting liaison with functional partners and BASIS to support issue resolution and quality control of naming convention and content prior to submission of deliverable to EOHHS
        • Oversee Attestation Management process as part of submission process
        • Oversee FTP Site Management to ensure accurate and timely upload of documents to EOHHS
        • Core Medicaid Contractual Program Support
          • Assume a leadership role and be the operational expert for various State mandated programs and associated reporting requirements
            • PCP Capitation Management
            • Electronic Visit Verification (EVV) program monitoring and oversight. -Review of exception report (i.e. member demographic, prior auth, etc.). -Load balancing of services to optimize member and provider experience
            • Operations Support
              • Support the COSMOS to CSP transition for the following: FAD to Rally; legacy member website to MyUHC.com 2.0, and on-going claims issue triage for pre/post migration activities
              • Analytic Support to Health Services Team for program design and evaluation
              • Coordinate and manage the Communication Tracking Approval & Governance (CTAG) process with internal partners (marketing, quality, operations, etc.) to support timely delivery to and approval by EOHHS of member facing marketing materials
              • Operations Analyst role to gather data from different sources and interpret and create clear and impactful presentations to the local leadership team and state partners
              • Fair Hearing Management and Oversight
                • Research the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit
                • Gather documentation and clinical information to either settle or enforce the health plan denial of services
                • Attend hearings with proper documentation accompanied by the Chief Medical Officer to present case
                • Report outcomes to legal services quarterly and claims and appeals department as appropriate
                • Claims Support
                  • Follow end to end yearly rate adjustments for issues and tracking
                  • Approve claim edits and SOP's
                  • Approve or deny timely filing claims
                  • Review, approve or deny member reimbursements
                  • Track auto adjudication vs manual processes
                  • Claims timeliness reporting
                  • Meet weekly with claims team to mitigate any issues or risks
                  • Oversee claim projects
                  • Work with the encounters team to investigate rejects
                  • Investigate and educate grievances such as balance billing 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:
                    • Bachelor's degree in Business, Finance, Health Administration, related field, or equivalent work experience
                    • 3+ years of experience working with a managed care organization, health insurer, or consultant in a health care organization
                    • 1+ years of experience working with reports from various systems including Microsoft
                    • Experience in analysis of business process and workflow and providing an evaluation, benchmark and/or process improvement recommendations -
                    • Experience gathering and documenting requirements from the client/business
                    • Experience with identifying gaps in processes and providing solutions
                    • Intermediate or higher proficiency in Excel and Sharepoint - Preferred Qualifications:
                      • Bachelor's degree in Business, Finance, Health Administration or related field
                      • 3+ years of experience in or exposure to Medicaid programs
                      • Financial or regulatory reporting experience
                      • Experience with UHG claims data system (SMART)
                      • Experience with CSP FACETS
                      • Appeals or Intake experience -
                      • Medical record or utilization management experience
                      • Ability to multitask including the ability to understand multiple products and multiple levels of benefits within each product - To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment. Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm) *All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. 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.

Keywords: UnitedHealth Group, Los Angeles , Senior Health Plan Reporting Analyst - Warwick, RI, Accounting, Auditing , Los Angeles, California

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