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Sr Healthcare Consultant, Health Plan Payer / Provider Operations

UnitedHealth Group

Eden Prairie, MN
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Job Details

744675 Sr Healthcare Consultant Health Plan Payer Provider Operations

Sr Healthcare Consultant, Health Plan Payer / Provider Operations (744675)

Position Description

As a Senior Consultant you'll provide consulting services to strengthen and improve health care operations that result in stronger financial returns and a healthier health care system. You'll use your strong strategic and business acumen to work closely with clients to define, develop and document business requirements to ensure needs are captured and critical deliveries are executed. This consulting career gives you the opportunity to travel and share in a mission that inspires. You'll see your ideas come to life and your achievements recognized. You won't find tougher challenges. And you won't find smarter people working together to solve them. Join us and start doing your life's best work.(sm)


You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.


Primary Responsibilities:

We are seeking candidates who have deep domain expertise and previous management consulting experience in one or more of the following areas of Health Plan Operations:

  • Health Plan Operations

    • Government Programs - Medicaid, Medicare Advantage, and Medicare Part D
    • PBM - Third party administrator of prescription drug programs, pharmacy, administration of claims and benefits, drug utilization, distribution, disease management, and volume purchasing
    • Clinical - Payer disease and utilization management, HIN, ICD10 business processes, technology assessment, planning, remediation and compliance
    • Core Admin & Project Management  - Cost containment, process improvement, provider contracting, project management and Health Care Reform
    • Product Development - Market assessments and sizing competitive intelligence, sales management and distribution, network development, and vertical integration

In addition, candidates must have domain expertise and previous management consulting experience in one or more of the following additional areas:

  • Payment Integrity

    • Claims Editing
    • Enrollment Integrity/Coordination of Benefits
    • FWA
    • Overpayment Identification
    • Claims auditing
    • Health care Subrogation / Third Party Liability
  • Claims Processing

    • Claims adjudication / processing activities for a core claims administrative system (Facets, QNXT, HealthRules, Ika, etc.)
    • Clinical editing systems (ClaimCheck, CES) configuration and operations
    • Claims reimbursement analysis
    • Claims research and adjustment
    • Claims Third Party Liability and subrogation processing
    • Claims system configuration: processing rules, edits and pends
    • Other health plan operations impacts on claims: provider contracting, referrals and authorizations, benefit plan design and configuration
  • Call Center

    • Member, Provider and Claims call center operations core administrative systems for call management, scheduling, CRM, IVR
    • Appeals and Grievance processes
  • Provider / Network

    • Provider contracting, provider relations and network development operations in a health plan
    • Provider portals

Required Qualifications:

  • 3+ years of experience working in a management role at a health plan or provider organization
  • 5+ years of experience working in a management consulting organization (big 4 preferred)
  • 5+ years of Healthcare experience in any of the following:

    • Government Programs, PBM, Clinical Health Management, Core Administer Delivery, Program Management, Product Management, or Network Management
  • 3+ years of experience in one or more of the following:

    • Operational business process improvement, business process analysis, benchmark analysis or workflow analysis
  • 1+ years of experience with client relationship management and expanding sales opportunities beyond current engagement
  • Ability to travel 80% (Mon-Thu) of the time or 100% (Mon-Fri) as needed

Preferred Qualifications:

  • Bachelor's degree obtained
  • Lean Six Sigma
  • PMO methodology experience
  • Quantitative ability to analyze data
  • Strong knowledge of Microsoft Office products with a focus on PowerPoint and Excel
  • Strong work ethic and desire to help clients improve their businesses

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)


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



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: consultant, consulting, healthcare, healthplan, payer, operations, management, travel, telecommute, telecommuter, telecommuting, remote, work from home, OptumConsulting

Job Details

  • Contest Number744675
  • Job TitleSr Healthcare Consultant, Health Plan Payer / Provider Operations
  • Job FamilyOptumInsight Consulting
  • Business SegmentOptumInsight

Job Location Information

  • Eden Prairie, MN
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelDirector
  • ShiftDay Job
  • TravelYes, 75 % of the Time
  • Telecommuter PositionYes
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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