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HEDIS Quality Risk Adjustment Technical SME

3 months ago

Eden Prairie, Minnesota, United States Optum Full time

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.

Primary Responsibilities:

  • Analyze, review, and trend complex healthcare data
  • Support short and long term operational/strategic business activities through analysis
  • Develop recommended business solutions through research and analysis of data and business process and implement when appropriate
  • Self-starter that demonstrates accountability for all assignments
  • Assess and interpret customer needs and requirements
  • Identify solutions to non-standard requests and problems
  • Solve moderately complex problems and/or conduct moderately complex analyses
  • Work with minimal guidance; seek guidance on only the most complex tasks
  • Translate concepts into practice
  • Provide explanations and information to others on difficult issues
  • Coach, provide feedback, and guide others
  • Act as a resource for others with less experience
  • Technical skill is required as this position is a mix of business and technical skills

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:

  • 1+ years of experience with healthcare claims analysis
  • 1+ years of experience; skilled in reading and writing moderate to complex SQL commands and accurately assessing results
  • 1+ years of experience analyzing HEDIS/Risk Adjustment metrics or Functional SME for HEDIS/Risk adjustment reporting
  • Proven ability to write clearly composed documentation for business requirements documentation as well as information that will be distributed to auditors
  • Proven ability to problem solve including multiple priorities and research conflicting and/or inaccurate data
  • Proven ability to travel up to 40% time; out on Sunday/Monday with return home on Thursday (or shorter trips)

Preferred Qualifications:

  • Experience with HEDIS vendor software a plus or experience with HEDIS reporting using other tools
  • Experience in Risk Adjustment submissions
  • Experience gathering requirements from the client/business and documenting
  • Experience with process improvement, workflow, benchmarking and / or evaluation of business processes
  • Project Management experience
  • Intermediate level of proficiency with PC based software programs and automated database management systems required (Excel, Access, PowerPoint)
  • Working knowledge of relational databases, database structures
  • SSIS ETL development

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


California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.



Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.



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.