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Job Details

UnitedHealth Group

CPM Provider Service Representative




Full Time


Phoenix, Arizona, United States

UnitedHealthcare is a company that's on the rise. We're expanding in multiple directions, across borders and, most of all, in the way we think. Here, innovation isn't about another gadget, it's about transforming the health care industry. Ready to make a difference? Make yourself at home with us and start doing your life's best work.(sm)

If you Reside in Arizona, you will enjoy the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Accountable for ownership of provider claim projects in an end-to-end process, from initial communication, identification of claim payment issue, facilitation of resolution of claim payment issues and communication of outcome
  • Ability to educate provider on details of UHG reimbursement policies. etc., and related claim issues for the Community & State products
  • Must possess a strong working knowledge of the Community & State products with the ability to interpret and apply Medicaid or Medicare guidelines, regulations, and mandated benefits
  • Interact directly with market providers and internal office staff in the resolution of claim issues
  • Resolve complex provider claim issues; support fellow team members and provide feedback to Leadership as needed
  • Maintain ongoing communication throughout the project process
  • Research claims to determine accuracy and identify high level root cause of any claim payment issues
  • Ensure consistent quality service to UHGs customers
  • Meet or exceed all productivity, turnaround time, and quality assurance expectations and guidelines
  • Research complex issues while navigating multiple platforms and databases
  • Work with project contact to gather information, prepare and submit claims for reconsideration, if applicable. Ensure accurate project submission based on the identified root cause
  • Upon project completion by CRT, audit project results, send rebuttals as necessary
  • Prepare and send project results to project contact, conduct final project contact call to review project outcome and ensure satisfaction with project results
  • Maintain documentation of all project activities and communications within the CPM application
  • Serve as primary point of contact for project submitters in resolution of claims project issues
  • Maintain compliance with all Federal/State regulations and UHG policies
  • Collaborate with other business partners to gather data needed for resolution
  • Works all provider types
  • Manages complex or escalated global projects
  • Escalated and formal complaint high volume projects

A Typical Day in the Life:

  • Perform root cause analysis on claim projects
  • Request and audit claim impact reports
  • Route impacted claims to the claim adjustment unit for re-processing
  • Perform backend audits to ensure claims were re-processed correctly
  • Communicate with internal and external business partners
  • Read and respond to emails
  • Complete training as required
  • Handle special projects assigned by manager
  • Make outbound calls to providers as required
  • Take ownership and follow through on outstanding issues
  • Serve as single point of contact for internal and external business partners for claim projects
  • Attend required calls

Skills/Traits to be successful in this role

  • Proven ability to understand physician, facility and ancillary provider contracts and the nuances of related claim issues
  • Experience and demonstrated understanding of physician, ancillary and facility contracting methodologies, contract loading and contract interpretation
  • Excellent Customer Service skills, ability to handle irate callers, gain the callers trust, take ownership of caller’s issue, and manage through to resolution
  • Ability to prioritize and effectively handle multiple priorities
  • Ability to schedule conference calls using applicable application
  • Attention to detail with a quality mindset
  • Critical thinking and problem analysis
  • Knowledge of claims processing procedures
  • Patience and Interaction skills to de-escalate frustrated providers
  • Critical thinking skills to assess complex issues and connect unrelated events
  • Collaboration skills to partner with other departments to achieve timely resolution
  • Persistence to follow through to completion when barriers are presented
  • Ability to work independently and make sound decisions in a fast-paced environment
  • Proven ability to manage multiple tasks, prioritize and meet deadlines under a heavy workload
  • Excellent follow up, organizational and change management skills required
  • Clear spoken voice and solid communication skills, both verbally and written
  • Adaptable to change

Skills You Will Gain:

  • Communication skills
  • Deeper understanding of business partners operations
  • Enhanced understanding of claim processing procedures
  • Big picture view of the organization
  • Ability to influence without authority
  • Broader network of internal contacts
  • Great opportunity comes with significant challenge. You'll be part of a performance driven, fast paced organization that is serving multiple markets and you'll be ensuring proper implementation of complex contracts

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction 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 (or higher) OR 4+ years of experience with applicable claims platform
  • 2+ years of customer service experience with claims review and issue resolution within community and state
  • 2+ years of experience with applicable claims platform
    • ACTIVE CSP FACETS access
  • 2+ years of experience with physician, facility, and ancillary claims
  • Intermediate level of proficiency in MS Office (Word, Excel, Outlook)
  • Reside in the state of Arizona

Preferred Qualifications:

  • Experience with NDB
  • Experience with MACESS
  • Experience with DOC 360
  • Experience with BCO
  • Experience with Enterprise Now and Team Track

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that’s second to none. This is no small opportunity. It's where you can do your life's best work.(sm)

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

For more information on our Internal Job Posting Policy, [Register to View] style="color:blue">click here.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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