UnitedHealth Group is among the most ambitious Fortune 25 companies you'll ever meet. Through our family of businesses, we're working to make the health care system perform better for more people, in more ways than ever.

Simply put, we think the entire system can be greater than it's ever been. And that drives us to work harder, aim higher, and expect more from one another.

Here, you'll be empowered to make an immediate impact for millions of others. And you'll achieve more than you ever expected. How does that fit with your plans?

UnitedHealth Group is an innovative leader in the health and well-being industry, serving more than 55 million Americans. Through our family of companies, we contribute outstanding clinical insight with consumer-friendly services and advanced technology to help people achieve optimal health. Ovations is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.   Imagine joining a group of professionals and clinicians who are working to improve health care for people over 50. Consider the influence you can have on the quality of care for millions of people. Now, enhance that success with enthusiasm you can really feel.   That's how it is at Ovations. Everyday, we're collaborating to improve the health and well being of the fastest growing segment of our nation's population. And we're doing it with an intense amount of dedication.   Claims Director- Management operations   Responsibilities include:   Establish and operate an end to end claim processing operation that will encompass oversight and/or coordination with customer services, network, and meeting all government SLA's and operational requirements.  The operations will include but not be limited to:   · Coordination of Benefits Program Oversight: Provide guidance to claims operations on calculation methodologies, coordinate the expansion and improvement of other insurance identification, managing projects to improve automation opportunities in either calculation methodologies or loading of other insurance information. Reimbursement Policy and Implementation: Manage clinical resources in claim operations, appeals, fraud and abuse. Responsible for medical payment policy, post-service prepayment review, and clinical support of member and provider disputes and appeals.  Assure compliance with all internal and external regulations and timelines, and manage claim analysis and affordability. · Management and expansion of adjudication edit tools:  Recommending and implementing payment policies to assure accurate adjudication of claims received and identification of invalid billing by providers, and identification of additional tools to identify billing inaccuracies and resulting claim overpayments. · Managing medical coding review operations:  Performed internally and externally through vendors to assure accurate payment against contracted payment methodologies.  Implement processes to assure identification of up coding and inaccurate billing with regard to services provided on an inpatient basis (e.g. Readmission reviews, hospital bill audits, etc.). · Supporting and resolving provider concerns: Resulting from recoupment activities including meeting with the providers to address specific concerns and aid in reducing instances where inaccurate billings are occurring. · Providing leadership in the development of payment trend reporting: By category of service, by specialty, etc. to identify inaccurate payment of claims or inappropriate payment of claims.  Identification is the start of the process but involves development of a root cause identification process with implementation of a resolution to the inaccurate payment processes.         BA/BS degree.  MBA or other advanced degree preferred 10 +  years progressive management experience of health care claims/reimbursement and operations to include 5+  years of senior leadership experience. Demonstrated track record of making timely business decisions, establish strategy and vision Demonstrated experience in managing large scale, enterprise level projects related to claim processing  systems Demonstrated ability to build and maintain creditability with senior executives, vendors, customers and team. Demonstrated ability to build and maintain high performing teams and managed multi- functional organizational structure. Demonstrated focus on overall customer experience and ensure high quality of service. Demonstrated ability to present information to a variety of audiences. Demonstrated financial and analytical skills; with experience in managing cost statements, readily identify drivers of lower-than-expected performance, and proactively seek performance improvements to meet necessary cost and customer service performance metrics. Demonstrated track record of maintaining overall department budget and financials.  Must have experience with Claim-based Analysis & Reporting including, cost of healthcare, process improvement/quality control, forecasting and staffing models, and budgeting. Demonstrated track record of continuous process improvement methodologies and application to claims environment.  Six Sigma or other process improvement methodology strongly preferred. Experience in evaluating, negotiating, and managing financial and operational arrangements with third party vendors.   Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V UnitedHealth Group is a drug-free workplace.  Candidates are required to pass a drug test before beginning employment.