Senior Analyst RCM

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization 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)

Required Qualifications :

Preferred Qualifications :

Technical skills :

Soft skills :

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.