Senior Provider Data Analyst & Resolution Specialist

What the role needs

• Schedule: Monday-Friday, 8:30am-5pm PST
• The role in this function is accountable for the full range of provider relations and service interactions within UHG, focusing on end-to-end provider claims, call quality, and network support
• Manage provider interactions and ensuring ease of the provider portal, including future service enhancements
• Supports the development and delivery of external provider education and training programs
• Assist the Manager and Leadership in updating and developing provider data, workflows, systems, and other processes
• Supports credentialing, recredentialing, enrollment and contracting processes, including Letters of Agreement (LOAs) ensuring compliance with NCQA or County standards
• Orders and supports Primary Source Verification for Providers
• Oversees and maintains updated provider credentialing documentation, including but not limited to DEA registration, clinical license, board certifications, and PLI
• Completes administrative processes related to the applications and supporting documents to ensure compliance with credentialing criteria for inclusion in the FFS and TERM provider networks
• Collaborates with cross-functional teams to ensure seamless execution of site-wide processes
• Responds to provider requests (emails, calls, mail correspondence, and faxes) and inquiries and direct them to appropriate internal or external resources
• Designs and implements programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers

From the employer

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together. This is a critical position within the Provider Services Department and a required position within our contract budget. This is a budgeted replacement position that is funded by the ASO contract with the County of San Diego. The position is critical to maintaining the Fee for Service Provider Network that we manage on behalf of the County. This position is responsible for processing the provider applications & contracts, completing the provider credentialing and re-credentialing. The Senior Provider Services Representative role is focused on managing provider networks that support the client base, including hospital, FFS and TERM networks. Responsibilities may include provider relation activities, analyzing provider performance, credential and recredentialed activities, and creating provider reimbursement arrangements. Demonstrates thoroughness and attention to detail to reviewing tasks and documents. Proactively engages in effective communication with diverse audiences and providers. Maintains tasks accuracy especially under tight work deadlines. Consistent with productivity goals and departmental expectations. Responsible for the full range of provider relations and service interactions. Works with Manager of Provider Services on processing applications and related documents; completing credentialing process in conjunction with Corporate Credentialing Department staff. Maintains and ensures the integrity of provider databases; responds to provider inquiries and provides exceptional customer service to providers, County partners, peers, staff in other departments and the general public. The Contract Administrator may work with providers on the TERM, and/or Medi-Cal Fee-For-Service (FFS) Network(s) as well as Off Panel, Out of Network providers, Skilled Nursing Facilities, Hospitals, which includes the San Diego County Psychiatric Hospital and/or Edgemoor Hospital, as well as other medical professionals. Location: This role will require working 2 days onsite at 3131 Camino del Rio North, Suite 700, San Diego CA, 92108. If you reside in San Diego, CA, you will enjoy the flexibility of a hybrid-remote* role as you take on some tough challenges. Schedule: Monday-Friday, 8:30am-5pm PST Primary Responsibilities: • The role in this function is accountable for the full range of provider relations and service interactions within UHG, focusing on end-to-end provider claims, call quality, and network support • Manage provider interactions and ensuring ease of the provider portal, including future service enhancements • Supports the development and delivery of external provider education and training programs • Assist the Manager and Leadership in updating and developing provider data, workflows, systems, and other processes • Supports credentialing, recredentialing, enrollment and contracting processes, including Letters of Agreement (LOAs) ensuring compliance with NCQA or County standards • Orders and supports Primary Source Verification for Providers • Oversees and maintains updated provider credentialing documentation, including but not limited to DEA registration, clinical license, board certifications, and PLI • Completes administrative processes related to the applications and supporting documents to ensure compliance with credentialing criteria for inclusion in the FFS and TERM provider networks • Collaborates with cross-functional teams to ensure seamless execution of site-wide processes • Responds to provider requests (emails, calls, mail correspondence, and faxes) and inquiries and direct them to appropriate internal or external resources • Designs and implements programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers • Contributes to the development and management of provider network strategies • Identifies gaps in provider network composition and services to assist the network contracting and development team in prioritizing contracting needs • Involved in identifying and remediating operational short-falls and researching and remediating claims • Follow up with providers to obtain the necessary supporting documents and attestations required for contracting to maintain their network participation • Ensure provider and group system setup forms are accurately completed and submitted to the appropriate internal departments for processing • Plans, prioritizes, and organizes and completes tasks to meet established goals and deadlines • Designs and delivers comprehensive, effective training that aligns with departmental goals and meets the needs of team members • Develop report templates and generate reports to support provider data analysis • Actively participates in meetings to support the achievement of departmental and cross-functional goals and objectives • Perform and accurately enter and update provider data across multiple databases used for directories, payments, mailing, and reporting • Maintain organized provider files for easy access by staff, leadership, and other departments • Conducts peer review of providers' files to ensure accuracy and current supporting documents • Document provider communication in designated systems and helps maintain database integrity by verifying and updating provider information during interactions • Provides support to Manager and Leadership in preparation for the annual audit • Performs additional duties as assigned by Manager to successfully support the Department, Leadership, provider networks, and team What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include: • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays • Medical Plan options along with participation in a Health Spending Account or a Health Saving account • Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage • 401(k) Savings Plan, Employee Stock Purchase Plan • Education Reimbursement • Employee Discounts • Employee Assistance Program • Employee Referral Bonus Program • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.) You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: • 3+ years of experience in healthcare analytics, provider data management, provider relations, claims operations, network management, or related healthcare operations • Experience investigating and resolving complex provider issues involving claims, contracting, credentialing, reimbursement, and provider data • Experience analyzing healthcare data and translating findings into actionable business recommendations • Experience working with provider databases and enterprise platforms such as TRES, SmartCare, SharePoint, SQL Server, or comparable systems • Advanced analytical and investigative skills with demonstrated ability to interpret complex datasets, identify trends, conduct root cause analyses, and recommend sustainable solutions • Proven knowledge of healthcare data flows, system dependencies, and impacts on provider operations and claims processing Preferred Qualifications: • Solid problem-solving, analytical, written, and verbal communication skills • Ability to communicate complex data findings, operational impacts, and recommendations to both technical and non-technical audiences • Proven ability to work independently while effectively collaborating with cross-functional teams • Demonstrated project management, facilitation, and stakeholder engagement experience • Proven ability to manage multiple priorities, investigations, and projects while meeting established deadlines • Ability to influence process improvements and drive issue resolution without direct authority • Demonstrated commitment to improving provider satisfaction, reducing provider friction, and enhancing provider network performance *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives. UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.