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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale.Join us to start Caring. Connecting. Growing together.

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

This position is responsible for quality audit, reporting, analysis and identifying compliance issues and remediation for programs to support continuous quality improvement using applicable tools.

The role of the Quality Business Operations Specialist is to:

• Perform/Measure/Document and Report Performance and Quality Audits- Perform internal quality audits to ensure accuracy of work (e.g., data entry; reporting; quality errors)
• Make appropriate corrections to identified discrepancies (e.g., incorrect dates; data errors)
• Communicate results to key stakeholders using internal procedures and documentation
• Conduct root cause analysis on performance metrics such as error trends
• Identify compliance risks, remediate errors and provide feedback to reduce errors and improve processes and performance
• Positions in this function may also be responsible for quality reporting, analysis, and audits, and for developing plans and programs to support continuous quality improvement using applicable tools
• Support/Coordinate/Perform Special Projects: Provide input into and/or create supporting documentation (e.g., reports; presentation materials) for special projects
• Provide information, assistance, and/or oversight to facilitate project implementation
• Demonstrate Knowledge of Operations Systems, Tools, and Processes -Demonstrate understanding of relevant federal and state regulatory guidelines (e.g., CMS)
• Demonstrate understanding of standard operating procedures, policies, and processes

Primary Responsibilities:

• Perform quality review of Medicare coverage determinations and cancel cases to determine the following 1) accuracy of review 2) timeliness 3) correctness of authorization placement 4) compliance errors 5) Adherence to Clinical Policies and Procedures
• Navigate multiple computer programs to review and document the accuracy of case reviews, report errors and remediate as directed
• Develop and maintain a clear understanding of Medicare policies and procedures
• Identify compliance issues and address escalated Medicare compliance issues to ensure compliance
• Identify and document errors and issues identified from case reviews
• Identify errors and Initiate and track individual case remediations
• Partner with other members of the team to evaluate adherence to policies and procedures
• Load daily cases for monitoring on Quality SharePoint
• Entering errors on the I/O Log
• Developing reports of quality review
• Meet case review goals

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:

• HS Diploma 
• Pharmacy Technician License in the state you reside
• 2 years of experience in Prior Authorization or related field
• 2 years of experience working with Medicare Part D rules and processing (especially compliance related)
• Intermediate proficiency with MS Office Products (Word, Excel, PowerPoint)

Preferred Qualifications:

• Active/current National Pharmacy Technician Certification (i.e., eXCPT, NCCT, PTCB) 
• Previous experience in using PAS and RxClaim systems 
• Sharepoint and Planner experience

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

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.

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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