UnitedHealth Group Compliance Specialist (PeoplesHealth) - New Orleans, LA in METAIRIE-Louisiana, Louisiana

Coordinate and perform the compliance and policy activities within the Claims Department to accomplish company and department objectives and regulatory requirements established by the Centers for Medicare and Medicaid Services (CMS), and Louisiana Department of Insurance (DOI), and other regulatory organizations.

The Compliance Specialist is responsible for monitoring and auditing current processes to ensure the Claims Department meets all regulatory and business requirements. The incumbent works closely with the Director of Claims and other key claims management staff to identify compliance required process improvement, develop action plans, and ensure effective implementation of new processes. In addition to Claims Department staff, the Claims Compliance Coordinator will interact with interdepartmental and outside resources when integral to the successful outcome of audits and compliance projects.

Primary Responsibilities

  • Completes internal monitoring activities for the department, including compiling data, analyzing results, coordinating with department leadership to correct deficiencies and communicating with the Compliance Department

  • Serves as Compliance Department contact for the department. Coordinate compliance activities between the Claims Department and the Compliance Department, including, but not limited to education, training, communication, reporting activities, internal monitoring, auditing, and corrective actions

  • Communicates and coordinates with department leadership to ensure compliance with all standards within the department

  • Maintains working knowledge of all applicable CMS, DOI, and other regulatory organization regulations

  • Works with Director of Claims and other key claims management staff to communicate regulatory requirements

  • Assists the department in preparation for CMS and other oversight entity audits

  • Reviews and monitors non par denials to ensure accurate processing

  • Verifies and analyzes the accuracy of all tasks, data and information used or generated by OMT; resolves any discrepancies or problems and closes tasks timely

  • Requests reports utilized for timely claims payment reporting and updates Claims Management with current data, as well as documents comments as needed

  • Prepares and submits quarterly organization determination reports that meet CMS requirements

  • Organizes and facilitates meetings to implement regulatory requirements

  • Performs quarterly reviews for identified risk items

  • Researches and provides regulatory guidance and interpretation to staff inquiries

  • Completes Learnsource modules timely

  • Exhibits very good written communication skills by thoroughly and accurately documenting processes, policies and procedures, training manual material, status reports, etc.

  • Identifies areas for improvement regarding all regulatory and oversight requirements and coordinates with Director of Claims to develop and then implement an action plan for process improvement as needed

  • Operates as a team player and develops strong working relationships to ensure open communication and coordinates compliance efforts at all levels within Claims Department and interdepartmentally

  • Reports issues to the Director of Claims and assists with correcting those issues as needed

  • Performs other duties as assigned by claims management staff.

Required Qualifications

  • Bachelor’s Degree or equivalent work experience

  • Prior knowledge with legal, compliance, claims or audit experience

  • Intermediate or better proficiency with MS Word, MS Excel and MS Outlook

  • Previous research experience, gathering and analyzing data

  • Must live within a commutable distance of this specific career opportunity

Preferred Qualifications

  • Bachelor’s Degree with an emphasis in law

  • Strong claims processing or auditing knowledge and experience

  • Excellent verbal and written communication skills

  • Medical terminology and/or ICD-10 coding knowledge

  • Previous compliance experience

  • Familiarity with CMS (rules and regulations) language and interpretation

Every day, UnitedHealth Group helps to make the health care system work better for everyone. It's work on a scale like you've never seen before. Come help us strengthen the healthcare system as you do your life's best work.(sm)

Careers at UnitedHealthcare Medicare & Retirement.

The Boomer generation is the fastest growing market segment in health care. And we are the largest business in the nation dedicated to serving their unique health and well-being needs. Up for the challenge of a lifetime? Join a team of the best and the brightest to find bold new ways to proactively improve the health and quality of life of these 9 million customers. You'll find a wealth of dynamic opportunities to grow and develop as we work together to heal and strengthen our health care system. Ready? It's time to do your life's best work.(sm)

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.

Job Keywords: Metarie, LA, New Orleans, Compliance Analyst, Compliance Specialist, Claims, Auditing, Legal, CMS, coding, regulatory