Subject Matter Expert - Denial Management or 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 A/R SME is responsible for overseeing and optimizing the accounts receivable processes, focusing on collection follow-up and denial management within the backend RCM operations. This role requires a deep understanding of the revenue cycle, excellent analytical skills, and the ability to implement effective strategies to maximize reimbursement and minimize denials.

Primary Responsibilities:

• Collection Follow-Up:
  • Monitor and follow up on outstanding insurance claims to ensure timely payment
  • Communicate with insurance companies, patients, and internal teams to resolve issues preventing claim finalization
  • Utilize collection software and tools to track and manage accounts receivable
• Denial Management:
  • Analyze and investigate claim denials to determine root causes
  • Develop and implement strategies to reduce denial rates and improve first-pass resolution
  • Prepare and submit appeals for denied claims, ensuring compliance with payer guidelines
• Data Analysis and Reporting:
  • Analyze A/R data to identify trends and areas for improvement
  • Generate reports on A/R performance, including aging reports, denial rates, and collection effectiveness
  • Provide insights and recommendations to leadership based on data analysis
• Process Improvement:
  • Identify and implement process improvements to enhance efficiency and effectiveness of A/R operations
  • Collaborate with other departments to streamline workflows and reduce bottlenecks
  • Stay updated on industry best practices and regulatory changes affecting A/R processes
• Training and Support:
  • Provide training and support to team members on A/R processes and best practices
  • Serve as a resource for complex A/R issues and escalations
  • Ensure team members are knowledgeable about payer requirements and denial management strategies
• Compliance and Documentation:
  • Ensure all A/R activities comply with HIPAA and other regulatory requirements
  • Maintain accurate and up-to-date documentation of A/R processes and procedures
  • Conduct regular audits to ensure compliance and identify areas for improvement
• Task:
  • As the position Implies, he/she should be the expert to the process he/she belongs to
  • Ensures that he/she is current as it relates to process updates
  • Attend scheduled meeting and calibration sessions
  • Review audit markdown and conduct error analysis and process related coaching including root cause analysis
  • Complete internal accounts audit as deemed required
  • Respond to query and/or provide feedback to business partners as necessary
  • Update dashboards, trackers, other process related files in a timely manner
  • Provide training needs analysis and education as needed
  • Provides Quality talks and related updates
  • Ensure accurate documentation of coaching sessions
  • Conduct daily or weekly huddle to discuss strategy to address performance or challenges, provide update and to drive performance
  • Prepare training materials and conduct new hire training and refresher courses as deemed necessary
  • Acts as POC in the absence of the supervisor
  • Submit rebuttals to failed audits in the absence of the supervisor
  • Send out the inventory plan for the team in the absence of the supervisor
  • Ensure that her/his collections skill are intact thus a requirement to process accounts at least 10 accounts/week for the process she/he belongs to. The requirement may increase depending on the need to keep the inventory at a manageable level
  • Strictly implement company policies and guidelines
  • Request needed learning from Onshore training team
  • Provide floor/virtual support to ensure that collectors are assisted real time
• 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:

• Bachelor's degree / Graduate
• 4+ years of experience in accounts receivable management, with a focus on collection follow-up and denial management in both Ambulatory and Acute
• Knowledge / Skills / Abilities:
  • Technical Skills:
    • Proficient in A/R management software and tools
    • Solid knowledge of medical billing and coding practices
    • Proven excellent analytical and problem-solving skills
  • Communication Skills:
    • Proven solid verbal and written communication skills
    • Proven ability to communicate effectively with internal and external stakeholders
  • Organizational Skills:
    • Proven solid organizational and time management skills
    • Proven ability to manage multiple tasks and priorities effectively
  • Interpersonal Skills:
    • Proven ability to work collaboratively within a team
    • Proven solid customer service orientation
  • Adaptability:
    • Proven ability to adapt to changing processes and technologies
    • Proven willingness to learn and stay updated on industry trends
    • In-depth knowledge of HIPAA regulations and compliance requirements

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.