Job
Description
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 SWOT (Special Work Operations Team) in Back Office RCM is responsible for handling complex and escalated claims within the US Healthcare Revenue Cycle Management (RCM) process. The team ensures efficient resolution of denied or aged claims, identifies root causes of payment delays, and implements corrective actions to improve revenue recovery. This role is crucial for improving cash flow, reducing bad debt, and ensuring financial stability for healthcare providers by optimizing the revenue cycle process. Primary Responsibilities: Claims Management: Investigate and resolve denied, aged, or complex medical claims to maximize reimbursement Denial Analysis & Resolution: Identify patterns in claim denials using CARC & RARC combinations, work on root cause analysis, and take corrective actions AR Follow-up: Perform follow-ups with insurance providers (Payers) to resolve outstanding balances as needed. This will include miscellaneous commercial payers follow up tip sheets & work arounds towards claims resolution Payer provider guidelines: Download, review, share and update teams in Front, Middle & Back functions (FMB) about the payer behavior impact on acute and ambulatory scope of work. Recommend registration teams check lists, provider liability waiver forms, edits and rules to be put in practice management system and clearing house for impactful cash collections Billing & coding guideline correlation & impact analysis: Should be able to connect dots between coding and billing combinations that must be billed for acute & ambulatory Process Optimization: Identify inefficiencies and suggest workflow improvements to enhance revenue cycle performance Compliance & Documentation: Ensure adherence to HIPAA, payer policies, and internal guidelines while maintaining accurate documentation along with industry regulations Collaboration: Work closely with Front, Middle & back functions (Registration, Eligibility & benefits, billing, coding, payment posting & AR) to streamline operational workflows and process flows by presenting As Is & To Be model for efficiency and efficacy Training & Knowledge Sharing: Train, coach and mentor team members aligned to by providing meaningful insights and best practices to enhance project performance Root cause analysis: Identify issues hindering resolution of claims by performing process deep dives (FMEA), RCA’s, audits / reviews wherever needed and recommend corrective and preventive actions (across FMB functions) Financial KPI management: Evaluate & comprehend logic behind KPIs like collection goals, denial %, rejections %, AR days, AR >90+% & provider bad debt (write offs) Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so Qualifications - External Required Qualifications: Bachelor's degree in finance, healthcare administration, business, or a related field 3+ years of experience in revenue cycle management, with at least 3+ years in a leadership/mentorship role Experience in AR follow-up, appeals, and dispute resolution Solid knowledge of US healthcare RCM, insurance claim adjudication, and denial management Knowledge of HIPAA and payer-specific policies Proficiency in RCM tools and healthcare billing software (eg, EPIC, eClinicalWorks, Athenahealth, etc) Proven solid analytical, problem-solving, and communication skills Proven ability to maneuver through ambiguity Preferred Qualification: Experience in process improvement methodologies (Lean, Six Sigma) Technical skills: Experience with revenue cycle software and electronic health record (EHR) systems Proficiency in Excel, SQL, Power BI, or Tableau for reporting Advance Excel and solid ability to analyze data, identify patterns Understanding of CPT, ICD-10, HCPCS and payer billing reimbursement methods Soft skills: Solid leadership, communication, and team management abilities Solid understanding of US healthcare RCM processes (Billing, Coding, Denials, AR, Payments, Compliance) Solid knowledge of medical billing, coding (CPT, ICD-10, HCPCS), payer contracts, and reimbursement methodologies Knowledge of regulatory compliance, including HIPAA and healthcare financial regulations Knowledge of RCA tools and their effectiveness Excellent written and verbal communication skills Excellent analytical, problem-solving, and decision-making skills Solid decision-making and problem-solving skills Ability to work independently and as a part of a team Role & responsibilities Preferred candidate profile
