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UnitedHealth Group is a healthcare and well-being company that’s dedicated to improving the health outcomes of millions around the world. We are comprised of
Fraud Waste Abuse and Error Appeals Team Lead
Location
United States
Posted
84 days ago
Salary
$72.8K - $130K / year
Seniority
Lead
No structured requirement data.
Job Description
Fraud Waste Abuse and Error Appeals Team Lead
UnitedHealth Group
This position is National Remote. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. 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. It may be necessary, given the business need, to work occasional overtime. We offer paid on-the-job training. The hours of training will be aligned with your schedule. Primary Responsibilities: - Provide assistance, give feedback, and request action in completing daily and monthly reporting, i.e. (Quality, Automation, Platforms) - Aid in writing and implementing process improvement ideas, processes, i.e., Process mapping, job aids, PNP (Policies and Procedures) - Create and present on - going development and educational training for production staff - Aid with daily inventory management, task assignment and ensure escalations are responded to timely - Be responsible for responding to complex coding case related questions placed on the SME/MD portal - Upload and assign Inventory for the Clinical teams - Communicate daily inventory directions to all Clinical teams - Monitor, escalate, and report inventory at risk for being out-of-compliance - Monitor, escalate and report inventory with interest bearing risks - Be responsible for supporting quality metric activities, including but not limited to the monthly questions for Quality Knowledge Test, enrollment and attend meetings as required - Provide detailed research on claims and complex coding cases that require research - Provide feedback/support for client and/or senior leadership meetings/presentations that include gathering key data/information and updating of forms/materials - Work with OGA and OPRO teams to ensure consistent processes and claim resolution - Assist internal teams with subject matter expertise such as appeals, QA, Second Set of Eyes, True Positive Rate Re-review, training, Root Cause, Clinical Program Optimization, Issue Resolution, PIRT and provider escalation teams - Be point of contact and perform administrative duties when the manager is out - Be available for questions via team chats and/or emails, provide coaching when employees need additional support - Own and be accountable in the creation, development, and upkeep of Clinical team job aids to ensure the information is consistent and up to date - Be responsible for creating and facilitating bi-weekly team huddles agenda topics and education - Co-own and drive employee experience engagement via action plan group activities - Participate in overarching organizations meetings i.e. (Town Halls, Manager meetings, Monthly Leadership Connect, leader Link Series) - Attend and provide feedback for meetings that impact business operations, i.e. (Management of Change, Work Force Management, Automations, Projects, Change Advisory Board, R&D/Ideation) - Other duties/Projects as assigned by leadership You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - High School Diploma / GED - Certified Coder AHIMA - OR - AAPC Certified coder (CPC, CCS, CCA,) - Must be 18 years of age OR older - 2+ years of experience as an AHIMA or AAPC Certified coder with 2+ years of CPT / HCPCS / ICD – 10 / CM coding experience - 2+ years of Fraud, Waste, Abuse and Error Clinical Appeals/Reconsiderations team and process experience - Understanding of Fraud, Waste, Abuse and Error principles and health insurance experience - Experience with Microsoft Word (create, edit, save, and send, Microsoft OneNote (utilize and update information), Microsoft Outlook (ability to send / receive emails and utilize calendar) and Intermediate Microsoft Excel (Vlookups, xlookups, pivot tables, etc.) - Knowledge of health insurance business, industry terminology, and regulatory guidelines - Intermediate to advanced computer skills (e.g., multiple systems experience, keyboarding skills, trouble - shooting IT concerns, etc.) - Ability to work full time (40 hours/week), Monday - Friday, with flexibility for occasional overtime or weekend needs Preferred Qualifications: - 1+ years of experience of UHC platforms (COSMOS, Facets and CPW and / or working with medical terminology or coding) and/or other adjudication platforms - Healthcare claims experience - Investigational and / or medical auditor auditing experience, including government and state agency auditing - Criminal Justice background and / or certified Fraud Investigation experience - Experience with Payment Integrity (Optum) Telecommuting Requirements: - Ability to keep all company sensitive documents secure (if applicable) - Required to have a dedicated work area established that is separated from other living areas and provides information privacy - Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service Soft Skills: - Highly organized with effective and persuasive communication skills - Strong, analytical, problem - solving and decision - making skills; ability to exercise good judgment - Exceptional telephone and client service skills; ability to interact professionally in challenging situations - Open to change and new information; ability to adapt in changing environments and integrate best practices - Desire to move into a leadership role - Strong communication skills with the ability to interpret data *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. 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. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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Job Description Role Summary - The Regional Medical Scientific Director (RMSD) is a credentialed (i.e., PhD, PharmD, OD, DO, or MD) therapeutic and disease expert who engages in bidirectional exchange of scientific or medical information with Scientific Leaders (SLs). The role provides balanced, factual, scientific information about non-product areas of interest to the Company and replies to scientific questions from SLs, including questions about Company products. The work of an RMSD is aligned to: Scientific Exchange, Research, Scientific Congress Support, and Scientific Insights. - RMSDs liaise between the scientific community and the Company to enhance the comprehension of scientific foundations and goals for approved, in-development, and active Company-sponsored trials and/or investigator-sponsored research studies. The RMSD serves as a role model for other field medical team members in ways that include on-boarding and/or sharing of therapeutic expertise. 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Please click here if you need an accommodation during the application or hiring process. As an Equal Employment Opportunity Employer, we provide equal opportunities to all employees and applicants for employment and prohibit discrimination on the basis of race, color, age, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability status, or other applicable legally protected characteristics. As a federal contractor, we comply with all affirmative action requirements for protected veterans and individuals with disabilities. For more information about personal rights under the U.S. Equal Opportunity Employment laws, visit: EEOC Know Your Rights EEOC GINA Supplement We are proud to be a company that embraces the value of bringing together, talented, and committed people with diverse experiences, perspectives, skills and backgrounds. The fastest way to breakthrough innovation is when people with diverse ideas, broad experiences, backgrounds, and skills come together in an inclusive environment. We encourage our colleagues to respectfully challenge one another’s thinking and approach problems collectively. Learn more about your rights, including under California, Colorado and other US State Acts U.S. Hybrid Work Model Effective September 5, 2023, employees in office-based positions in the U.S. will be working a Hybrid work consisting of three total days on-site per week, Monday - Thursday, although the specific days may vary by site or organization, with Friday designated as a remote-working day, unless business critical tasks require an on-site presence.This Hybrid work model does not apply to, and daily in-person attendance is required for, field-based positions; facility-based, manufacturing-based, or research-based positions where the work to be performed is located at a Company site; positions covered by a collective-bargaining agreement (unless the agreement provides for hybrid work); or any other position for which the Company has determined the job requirements cannot be reasonably met working remotely. Please note, this Hybrid work model guidance also does not apply to roles that have been designated as “remote”. The salary range for this role is $190,800.00 - $300,300.00 This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. An employee’s position within the salary range will be based on several factors including, but not limited to relevant education, qualifications, certifications, experience, skills, geographic location, government requirements, and business or organizational needs. The successful candidate will be eligible for annual bonus and long-term incentive, if applicable. We offer a comprehensive package of benefits. Available benefits include medical, dental, vision healthcare and other insurance benefits (for employee and family), retirement benefits, including 401(k), paid holidays, vacation, and compassionate and sick days. 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All CVs / resumes submitted by search firms to any employee at our company without a valid written search agreement in place for this position will be deemed the sole property of our company. No fee will be paid in the event a candidate is hired by our company as a result of an agency referral where no pre-existing agreement is in place. Where agency agreements are in place, introductions are position specific. Please, no phone calls or emails. Employee Status: Regular Relocation: No relocation VISA Sponsorship: No Travel Requirements: 50% Flexible Work Arrangements: Remote Shift: Not Indicated Valid Driving License: Yes Hazardous Material(s): n/a Job Posting End Date: 04/17/2026*A job posting is effective until 11:59:59PM on the day BEFORE the listed job posting end date. Please ensure you apply to a job posting no later than the day BEFORE the job posting end date.
Job Description Role Summary - The Regional Medical Scientific Director (RMSD) is a credentialed (i.e., PhD, PharmD, OD, DO, or MD) therapeutic and disease expert who engages in bidirectional exchange of scientific or medical information with Scientific Leaders (SLs). The role provides balanced, factual, scientific information about non-product areas of interest to the Company and replies to scientific questions from SLs, including questions about Company products. The work of an RMSD is aligned to: Scientific Exchange, Research, Scientific Congress Support, and Scientific Insights. - RMSDs liaise between the scientific community and the Company to enhance the comprehension of scientific foundations and goals for approved, in-development, and active Company-sponsored trials and/or investigator-sponsored research studies. The RMSD serves as a role model for other field medical team members in ways that include on-boarding and/or sharing of therapeutic expertise. Location details: This role covers Florida & Puerto Rico. Candidates must reside within the territory and can travel up to 50% (with some overnight) within the territory. Responsibilities and Primary Activities Scientific Exchange - Develops professional relationships and engages with national and regional SLs to ensure access to company-approved medical and scientific information on areas of therapeutic interest and Company products - Conducts peer-to-peer scientific discussions and maintains a reliable presence with those SLs to ensure they have a medical contact within the company - Addresses scientific questions and directs SL inquiries on issues outside of RMSD scope (e.g., grants) to appropriate company resources consistent with applicable policies - Maintains current knowledge and comprehension of dynamic scientific and clinical environment in the Company's Areas of Interest (AOI) for the RMSD’s specific therapeutic area. Research - Upon request from Global Center for Scientific Affairs (GCSA), - Initiates discussions with SLs and/or potential investigators that include scientific/data exchange within our AOI to determine the alignment with our research strategies, studies concepts, scientific merit, and qualifications for a specific compound or trial - Enhances the comprehension of the scientific foundations and goals of investigator-sponsored research - Identifies barriers to patient enrollment and retention efforts to achieve study milestones - Upon request from Global Clinical Trial Operations (GCTO), - Recommends study sites and identifies potential investigators to participate in phase II-IV clinical development programs, conducts Site Initiation Visits (SIVs), and detects barriers to patient enrollment and retention efforts to achieve study milestones. - Protocol lead responsibilities in collaboration with GCTO - Addresses questions from investigators and provides information regarding participation in Company-sponsored clinical studies Scientific Congress Support - Engages in scientific congresses and medical meetings, facilitates scientific and data exchange for both Company and competitor data. Scientific Insights - Gathers feedback, data, or information during routine activities that can help the company better comprehend medical or scientific needs, priorities, or concerns of SLs and/or patients Inclusive Mindset and Behavior - Demonstrates eagerness to contribute to an environment of belonging, inclusion, equity, and empowerment - Leads by example and serves as a role model for creating, leading, and retaining a diverse and inclusive workforce Required Qualifications, Skills, & Experience Minimum - PhD, PharmD, OD, DO, or MD - Proven competence and a minimum of 2 years of Eye Care experience beyond that obtained in the terminal degree program - Ability to conduct doctoral-level discussions with key external stakeholders - Dedication to scientific excellence with a strong focus on scientific education and dialogue - Excellent stakeholder management, communication, and networking skills - A thorough comprehension of FDA, OIG, HIPAA, and other ethical guidelines, laws, and regulations relevant to the pharmaceutical industry and its customers - Ability to organize, prioritize, and work effectively in a constantly changing environment - Strong working knowledge of Microsoft Office Suite (Word, PowerPoint, Excel, Teams, OneNote) - Familiarity with virtual meeting platforms - Desire to contribute to an environment of belonging, engagement, equity, and empowerment by: - Working to transform the environment, culture, and business landscape - Leveraging diversity and inclusion to ensure business value, per global diversity and inclusion strategy - Ensuring accountability to drive an inclusive culture - Strengthening the foundational elements of diversity - Consistent adherence to field and corporate policies and Global Medical Scientific Affairs (GMSA) strategy, including field standard operating procedures (SOPs), Good Clinical Practice (GCP) guidelines, and administrative/operational responsibilities Preferred - Retina field-based medical experience Required Skills: Clinical Care, Clinical Research, Medical Affairs, Ophthalmology, Pharmaceutical Medical Affairs Preferred Skills: Current Employees apply HERE Current Contingent Workers apply HERE US and Puerto Rico Residents Only: Our company is committed to inclusion, ensuring that candidates can engage in a hiring process that exhibits their true capabilities. Please click here if you need an accommodation during the application or hiring process. As an Equal Employment Opportunity Employer, we provide equal opportunities to all employees and applicants for employment and prohibit discrimination on the basis of race, color, age, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability status, or other applicable legally protected characteristics. As a federal contractor, we comply with all affirmative action requirements for protected veterans and individuals with disabilities. For more information about personal rights under the U.S. Equal Opportunity Employment laws, visit: EEOC Know Your Rights EEOC GINA Supplement We are proud to be a company that embraces the value of bringing together, talented, and committed people with diverse experiences, perspectives, skills and backgrounds. The fastest way to breakthrough innovation is when people with diverse ideas, broad experiences, backgrounds, and skills come together in an inclusive environment. We encourage our colleagues to respectfully challenge one another’s thinking and approach problems collectively. Learn more about your rights, including under California, Colorado and other US State Acts U.S. Hybrid Work Model Effective September 5, 2023, employees in office-based positions in the U.S. will be working a Hybrid work consisting of three total days on-site per week, Monday - Thursday, although the specific days may vary by site or organization, with Friday designated as a remote-working day, unless business critical tasks require an on-site presence.This Hybrid work model does not apply to, and daily in-person attendance is required for, field-based positions; facility-based, manufacturing-based, or research-based positions where the work to be performed is located at a Company site; positions covered by a collective-bargaining agreement (unless the agreement provides for hybrid work); or any other position for which the Company has determined the job requirements cannot be reasonably met working remotely. Please note, this Hybrid work model guidance also does not apply to roles that have been designated as “remote”. The salary range for this role is $190,800.00 - $300,300.00 This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. An employee’s position within the salary range will be based on several factors including, but not limited to relevant education, qualifications, certifications, experience, skills, geographic location, government requirements, and business or organizational needs. The successful candidate will be eligible for annual bonus and long-term incentive, if applicable. We offer a comprehensive package of benefits. Available benefits include medical, dental, vision healthcare and other insurance benefits (for employee and family), retirement benefits, including 401(k), paid holidays, vacation, and compassionate and sick days. More information about benefits is available at https://jobs.merck.com/us/en/compensation-and-benefits. You can apply for this role through https://jobs.merck.com/us/en (or via the Workday Jobs Hub if you are a current employee). The application deadline for this position is stated on this posting. San Francisco Residents Only: We will consider qualified applicants with arrest and conviction records for employment in compliance with the San Francisco Fair Chance Ordinance Los Angeles Residents Only: We will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance Search Firm Representatives Please Read Carefully Merck & Co., Inc., Rahway, NJ, USA, also known as Merck Sharp & Dohme LLC, Rahway, NJ, USA, does not accept unsolicited assistance from search firms for employment opportunities. All CVs / resumes submitted by search firms to any employee at our company without a valid written search agreement in place for this position will be deemed the sole property of our company. No fee will be paid in the event a candidate is hired by our company as a result of an agency referral where no pre-existing agreement is in place. Where agency agreements are in place, introductions are position specific. Please, no phone calls or emails. Employee Status: Regular Relocation: No relocation VISA Sponsorship: No Travel Requirements: 50% Flexible Work Arrangements: Remote Shift: Not Indicated Valid Driving License: Yes Hazardous Material(s): n/a Job Posting End Date: 04/17/2026*A job posting is effective until 11:59:59PM on the day BEFORE the listed job posting end date. Please ensure you apply to a job posting no later than the day BEFORE the job posting end date.


