Key skills
PBM claims processingMedicare claimsMedicaid claimsRequirements gatheringProcess improvementExcelTableauCognosRxclaimCommunication
About this role
Optum is a global organization that delivers care aided by technology to improve health outcomes. The Claims SME will serve as the subject matter expert on the ORX Claims system, handling claims processing expertise and assisting in client-specific implementations and testing.
Responsibilities:
- Serves as the primary OptumRx contact for the Health Plan client for Claims processing expertise, day to day management of IBX inquiries
- Must have solid communication skills
- Assist the account team with research, running ad hoc reporting requests, claims research, and client projects
- Work with operational areas on any development requests that require enhancements prioritizing and validation post the fix
- Assisting in any client specific implementations of new programs and testing as needed
- Proactive reject report review
- Attend client facing compliance meetings and on an as needed basis
- QA of impact (BIA) analysis
- Adhoc QA of new plan builds and plan changes as required
Requirements:
- 3+ years of experience in PBM business / RXclaims
- 3+ years PBM claims processing experience
- 1+ years of experience navigating through Medicare and Medicaid Claims issue investigations
- 1+ years of experience gathering requirements from the client / business and documenting
- 1+ years of experience with process improvement / streamlining
- Advanced level of proficiency with PC based software programs and automated database management systems (Excel)
- Comfort with client facing
- Experience using Tableau, Cognos, Rxclaim
- Proven ability to communicate analysis including trends and opportunities to clients and the business in writing and verbally
- Proven ability to solve problems including multiple priorities and research conflicting and/or inaccurate data