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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, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Senior Director Optum Health Payment Integrity will responsible for managing Payment Integrity (PI) operations for Optum Health including the oversight of vendor delivered programs.

This includes oversight of vendor implementations, vendor management and ongoing operational delivery functions for all programs. The senior director will lead teams accountable for the execution of ACE, CES, Itemized Bill Review, Professional & Facility audit, outpatient audit, data mining, credit balance, subrogation, fraud and abuse, and coordination of benefits.

They will be responsible for driving multi-year growth strategies, collaborating with business partners and markets, creating staffing and financial forecasting, monitoring KPI’s, enabling automation, as well as ongoing opportunity identification and benefit analysis. Tactical functions include claims processing, capacity analysis planning and reporting, data integrity, CMS and compliance adherence, vendor management, inventory management, operations management, and forecasting. The senior director of Optum Health PI will need to work with numerous matrix partners to manage deliverables, provide policy expertise, communicate change, and manage escalations.

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

Primary Responsibilities:

• Accountable for execution of all Payment Integrity suite of products; pre and post pay operations. Professional and facility.

• Provide leadership over delivery and vendor teams to ensure delivery on gross and incremental savings targets

• End to end process ownership for Optum Health PI

• Identify, implement, and report opportunities to improve processes, procedures, systems

• Develop solid partnership with matrixed partners and stakeholders

• Provide market-facing support to support escalations, communicate change, and deliver budgeted savings

• Collaborate with a wide variety of matrix partners including but not limited to; healthcare economics, network management, claims operations, compliance, and regional and national medical directors, finance, internal and external vendors, UHC, OGA

• Lead program management for Optum Health PI services. Coordinating with vendors to improve performance, expand scope of services, reduce abrasion, and increase savings

• Manage deliverables to achieve set targets.

• Align staffing volumes/needs with savings forecasts and volumes

• Deliver expert vendor management practices to ensure that operational processes are standardized across multiple vendors and internal programs

• Drive favorable program outcomes across 15 integrated markets and 2 non-integrated.

• Document and communicate outcomes of claims investigations/overpayment/prepayment reviews to applicable stakeholders

• Manage multiple line of business with varying regulations and compliance rules

• Effectively plan staff responsibilities and manage vendor deliverables to meet department goals

• Lead and collaborate with claim operations team to identify ‘shift left’ opportunities to drive reductions in recovery adjustments

• Manage domestic and OGA work inventories

• Demonstrate understanding of applicable federal, state, and local compliance regulations (e.g., DOI, DOL, Healthcare Reform/PPACA, CMS) and ensure adherence

• Ensure all operational metrics are met

• Closely monitor provider abrasion and manage within controls; driving quality improvement, true positive increases, and appeal rate reductions.

• Deliver business requirements for savings and operational metrics dashboard reports

• Understanding of claims processing end-to-end

• Lead implementation management for any program expansions, market expansions

• Develop cost benefit analysis for proposed program expansions

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:

• 10 + years of Payment Integrity and/or claims operations experience. High level of knowledge across all PI value streams; capable of aligning to and driving Optum Health PI strategy

• 7+ years of healthcare operations; working within a health plan and/or managed care business operations

• 7+ years of progressive leadership including leading operations and/or business processes

• Medicare experience

• Vendor management experience

• Experience coordinating and navigating complex matrixed organizations

• Experience managing a comprehensive portfolio of programs

• Proven solid consulting and/or influencing skills; proven results as a performance consultant

• Proven ability to manage competing priorities, make decisions, and effectively execute across a large, complex fast faced organization

Preferred Qualifications :

• Certified Coder in ICD 10 and ICD 9 or RN/LPN

• Lean Six Sigma (Green belt/Kaizen)

• Experience in forecasting and budget management

• Experience developing and managing operational metrics

• All LOB (Medicaid, Medicare, Commercial) expertise

• Proven degree of interpersonal and relationship building skills to engage clients

• Demonstrated ability to gather and analyze information from multiple sources and use to form a cohesive and comprehensive recommendation or problem solution

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

California, Colorado, Connecticut, Hawaii, Maryland, Nevada, New Jersey, New York, Rhode Island, Washington, Washington, D.C. Residents Only: The salary range for this role is $147,300 to $282,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. 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.

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 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.