Description

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.

The Associate Director of Clinical Operations is responsible for leading Clinical Itemized Bill Review (IBR) operations supporting UnitedHealthcare and commercial payer clients. As a Registered Nurse with extensive expertise in healthcare revenue cycle, facility reimbursement, and payment integrity, this leader drives clinical review strategies that identify reimbursement opportunities, support accurate claim adjustments, and ensure compliance with CMS guidelines and client requirements.

This role provides leadership for a team of clinical leaders and reviewers, while partnering with resources to support operational consistency and business objectives. The Associate Director serves as the primary clinical subject matter expert for the IBR product, supporting complex client and provider discussions involving inpatient and outpatient facility billing, reimbursement methodologies, and adjustment rationale.

The position plays a critical role in advancing product strategy, developing clinical review methodologies, and delivering significant financial value through accurate, defensible, and clinically sound claim reviews.

This position combines clinical leadership with deep expertise in facility reimbursement and healthcare revenue cycle operations. The Associate Director serves as a trusted advisor and recognized subject matter expert, influencing clinical review methodology, product strategy, client outcomes, and reimbursement accuracy across a high-impact payment integrity program. The Associate Director functions as a recognized authority on facility reimbursement and payment integrity, influencing policy, product strategy, client outcomes, and significant savings opportunities across a multi-million-dollar business.

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

Primary Responsibilities:

Clinical & Operational Leadership

• Lead day-to-day clinical operations for pre-payment and post-payment facility claim reviews
• Manage and develop clinical leaders and staff to achieve productivity, quality, and financial objectives
• Monitor operational performance and drive process improvements to enhance efficiency and outcomes
• Partner with offshore resources to support consistent execution of clinical review activities

Payment Integrity & Revenue Cycle Expertise

• Serve as a senior clinical resource for complex inpatient and outpatient facility claim reviews
• Apply advanced knowledge of CMS guidelines, hospital billing practices, reimbursement methodologies, and payment integrity concepts to identify reimbursement opportunities and support adjustment recommendations
• Ensure review findings are clinically sound, compliant, and defensible

Product, Client & Provider Leadership

• Act as the primary clinical SME for the IBR product and review methodologies
• Participate in client, provider, and leadership discussions involving complex reimbursement and billing issues
• Clearly communicate adjustment rationale, clinical findings, and reimbursement concepts to internal and external stakeholders
• Support escalated client and provider inquiries requiring advanced clinical and reimbursement expertise

Policy & Strategy

• Lead the development and maintenance of clinical review concepts, reimbursement policies, and audit methodologies
• Partner with product and technology teams to enhance review capabilities and operational effectiveness
• Monitor regulatory and industry changes to ensure review methodologies remain current and effective
• 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.

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:

• Active, unrestricted Registered Nurse (RN) license
• 5+ years of experience in healthcare revenue cycle, payment integrity, facility reimbursement, or related healthcare operations
• 2+ years of experience reviewing and analyzing inpatient and outpatient facility claims
• 2+ years of experience applying CMS guidelines, UB-04 billing requirements, revenue codes, MS-DRGs, APCs, hospital charging practices, and reimbursement methodologies
• 1+ year of leadership experience managing clinical staff and leading cross-functional initiatives
• 1+ year of experience presenting complex adjustment rationale and reimbursement concepts to clients, providers, and senior leadership

Key Competencies

• Facility Payment Integrity Expertise
• Healthcare Revenue Cycle Knowledge
• Clinical Reimbursement Analysis
• CMS Regulatory Expertise
• Strategic Leadership
• Client & Provider Consultation
• Operational Excellence
• Process Improvement & Innovation
• Relationship Management
• Executive Communication

*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 salary for this role will range from $112,700 - $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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.

UnitedHealth Group is 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 is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.