Claims Business Process Consultant

UnitedHealth Group•Jersey City, NJ

About The Position

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 optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together Position Summary The Medicaid Health Plan Claims Business Process Consultant is responsible for reviewing, and analyzing claims submitted under the Medicaid program. This position ensures compliance with federal and state Medicaid regulations, accuracy of claim payments, and timely resolution of claim issues. The Claims Business Process Consultant collaborates closely with internal partners across the Health Plan and National support team to resolve discrepancies and support optimal claims management. 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 8:00 am - 5:00 pm.

Requirements

High School Diploma / GED
Must be 18 years of age OR older
Must have a valid driver's license
2+ years of customer service or provider service experience
2+ years of experience in medical health insurance claims processing
Experience with Medicaid regulations, billing codes (ICD, CPT, HCPCS), and claims adjudication processes
Proficiency with claims management software
Experience with Microsoft Excel (Create and Edit Spreadsheet, Use Formulas, create Pivot Tables)
Must be able to travel up to 25%25 of the time within NJ, travel will be conducted by driving
Ability to work 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 8:00 am - 5:00 pm.

Nice To Haves

Experience with Medicaid plans
Experience in a Provider facing role
Experience in ownership of internal/external stakeholder relationships
Works independently and collaboratively in a fast paced environment
Exceptional attention to detail and a commitment to accuracy
Excellent analytical, organizational, and communication skills

Responsibilities

Review and process Medicaid health plan claims to ensure accuracy, completeness, and compliance with all applicable guidelines and policies
Investigate and resolve claim discrepancies, denials, and appeals, coordinating with providers, members, and other stakeholders as necessary
Apply knowledge of Medicaid billing codes, reimbursement methodologies, and coverage criteria to adjudicate claims appropriately
Identify patterns of errors, fraud, waste, or abuse and escalate as needed to management or the Special Investigations Unit (SIU)
Maintain up-to-date knowledge of Medicaid program changes, policies, and procedures to ensure ongoing compliance
Document claim decisions and actions in the claims processing system with accuracy and attention to detail
Respond to inquiries from providers, members, and internal teams regarding claim status and resolution
Contribute to process improvement initiatives by identifying inefficiencies or recommending enhancements in claims operations
Conducting provider training and education