Job Description

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.



We have a position open for a Business Analyst to support the Optum Quality Measure Engine (QME) Team. HEDIS (Healthcare Effectiveness Data and Information Set) analytics tool which is widely used by health care employers to measure the performance of different medical care and service called QME analytical platform that caters to project reports within RQNS portfolio. This was designed to be the one stop solution for all analytics needs which can assess the providers and payers' performance and caters STAR ratings, certifying NCQA measures, health plan accreditation, STARS, as well as API outcomes.



Primary Responsibilities:


• As a Business System Analyst, candidate should be responsible for performing business analysis, systems analysis, conduct brainstorming sessions on the gaps of the process
• Identify issues and research on claims data for assigned healthcare measures
• Proactively review member data, claims data and system rules, by reading HEDIS document
• Should be from clinical, and claims background to determine which rules can be presented to the payer for new medical cost savings opportunities
• Candidate must work closely with data and analyze the data to provide solutions to improve business processes
• Stay current on client configuration and new CES functionality to recommend the most effective rule design
• Conduct root cause analysis, including investigation into Knowledge Base updates, LCD updates, and rule logic defects, to recognize and remediate escalated issues
• Should be able to understand ICD-9 / ICD-10 / SNOMED-CT / ICD-O-3 / LOINC / E-prescription / Rx Eligibility
• Define, create, and maintain rule requirements
• Building out non-proprietary and proprietary rule library: proactively share information with internal client teams
• Serve as a mentor to new Business Analysts, and routinely identify, develop, and share best practice experience with peers
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:


• HEDIS Experience
• 3+ years of Healthcare Industry experience (Healthcare reimbursement, claims adjudication, procedure/diagnosis coding knowledge)
• 3+ years of Medicare/Medicaid policy guideline experience
• 3+ years of experience performing Analysis and interpretation of business needs around client payment policies and translate into Business Requirements
• 3+ years of proven ability to interpret technical requirements and business requirements while coordinating with technical staff to help drive solutions for our customers
• 3+ years of proven ability to translate highly complex detailed clinical/technical solution concepts and articulate to technical and non-technical audiences
• 3+ years of experience interfacing with Clients
• 1+ years of experience interfacing at the Executive level
• HEDIS knowledge, good to have STARS rating / Part C / Part D
• Should be Proficient in CMS Measures, PQRS, HEDIS, Custom Measures
• Need testing experience on member data, claims data and should have extensive experience in analyzing patient records
• Good US Health Care experience with HEDIS domain expertise
• Extensive experience in gathering the requirements, working with development team on function enhancements, Unit testing, perform code review
• Need testing experience on member data, claims data and should have extensive experience in analyzing patient records
• Agile
• Knowledge on data abstraction to improve ratings
• Proven good analytical and communication skills and a positive attitude
• Flexible for the night shifts (15 days in a 5 months)
• Proficient with MS Office Applications


Preferred Qualifications:


• Bachelor's Degree
• Experience with CES, Claims Manager
• Content Manager experience
• Business Analyst software support experience
• Training experience
• Medical Coding experience or certified medical coder (AHIMA or CPC)
• SQL or Oracle query experience


Soft Skills:


• Solid analytical and troubleshooting skills
• Excellent interpersonal, written, and verbal communication skills
• Ability to manage multiple priorities and execute deliverables on time
• Demonstrated outstanding time management skills
• Ability to shift priorities quickly, handling multiple tasks and competing priorities
• Highly motivated and innovative, with the ability to work as part of a high-performance team as well as independently
• Demonstrated competency in large-scale organizations within a matrix environment


•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.•