Manager Claims Quality

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.

Position in this function is responsible for driving process excellence, reducing inefficiencies, and improving the accuracy and innovation for cost optimization. This role involves data-driven quality monitoring, identifying non-value-added (NVA) steps, leading lean projects, optimizing capacity planning, and ensuring continuous process improvement. The manager will work closely with operations, analytics, and automation teams to enhance overall RCM performance and compliance with regulatory guidelines across multiple capabilities and roles.

Primary Responsibilities

• Data-Driven Quality Assurance, Innovation and Process Optimization
• Develop and implement quality monitoring programs across various RCM functions, including charge entry, coding, billing, payment posting, AR follow-ups, and denials management
• Conduct data-driven root cause analysis to identify errors, inefficiencies, and compliance risks in RCM workflows
• Implement smart audit frameworks to track quality KPIs and error trends, leveraging automation and anomaly detection
• Identify and eliminate non-value-added (NVA) steps in RCM workflows to improve productivity and reduce turnaround time
• Work with IT and automation teams to design rules-based audit processes to reduce manual touchpoints
• Data Analysis, Insights for Continuous Improvement & Reporting Responsibilities
• Develop and maintain automated dashboards to monitor key performance indicators (KPIs) across claims processing, denials, AR follow-ups, and payment posting
• Perform trend analysis on denials, payment delays, and claim rejections, identifying patterns to improve first-pass resolution rates
• Analyze capacity planning data to optimize resource allocation and improve productivity in RCM teams
• Monitor SLAs, turnaround times, and accuracy rates, providing insights to leadership for strategic decision-making
• Analyze historical data to identify trends, patterns, and root causes affecting revenue cycle performance
• Generate monthly and quarterly reports for senior management, offering insights into quality trends, efficiency improvements, and risk areas
• Track and analyze denial patterns by payer, procedure code, and provider to develop targeted resolution strategies
• Partner with automation teams to integrate predictive analytics models for anomaly detection and process optimization
• Process Improvement & Cost Optimization
• Lead projects to streamline RCM operations and reduce rework. Implement continuous improvement initiatives (Kaizen, PDCA, DMAIC) to enhance efficiency in billing, Cash and AR follow-ups
• Work with stakeholders to optimize workforce allocation and queue prioritization in AR follow-up and denial management
• Reduce non-productive touches in AR and enhance resolution-based auditing by refining smart logic rules
• Performance Monitoring & Compliance
• Establish opportunities to track and improve efficiency on KPIs & SLAs such as first-pass claim resolution rate, denial rates, appeal success rates, and rework percentages
• Ensure compliance with payer guidelines, HIPAA, CMS regulations, and internal SOPs to minimize financial risk
• Forecasting & Data Projections
• Utilize historical performance data to forecast denial trends, claim rejection rates, and reimbursement timelines
• Predict staffing and resource needs based on workload trends, seasonal fluctuations, and payer behavior changes
• Develop models to project the impact of process changes on revenue, productivity, and cost savings
• Forecast capacity planning by analyzing work volume patterns and aligning workforce allocation accordingly
• Implement AI-driven predictive analytics to anticipate and mitigate revenue leakage
• 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

Required Qualifications

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.

Skills Required

Trend Analysis, Predictive Analytics, meditech, epic, anomaly detection, Root Cause Analysis, nextgen, Dmaic, Kaizen, Capacity Planning, Cerner, Pdca, Automation