Senior Director, Payer Administration

Senior Director, Payer Administration

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 to start Caring. Connecting. Growing together.

Join our team at Optum Insight, where we are leveraging cutting-edge AI and machine learning technologies to revolutionize healthcare delivery, enhance customer engagement, and drive innovation across our digital platforms.

The Senior Director, Payer Administration is charged with working across Optum and UnitedHealthcare Payment Integrity to help drive forward our multi-payer / provider real-time settlement initiative to drive transparency and eliminate waste throughout the healthcare ecosystem. In this role, the expectation is to provide both strategic and tactical execution to move the organization towards a more retail like experience for providers. This individual will be responsible for defining the evolution of Payment Integrity capabilities by value stream (technology, features, and integration into new data and APIs), revamped revenue model, and the development of a transition roadmap moving from legacy products to AI enabled real-time solutions deployed in the new ecosystem.

This position follows a hybrid schedule with four in-office days per week and must be located in either Eden Prairie, MN or Washington DC.

Primary Responsibilities :

• Champion the strategic vision for AI adoption by aligning initiatives with organizational goals to unlock value, drive competitive advantage, and ensure responsible, transparent, and impactful outcomes.
• Lead the ethical transformation of business processes and culture through AI integration that enhances efficiency, innovation, and decision-making.
• Definition of scope and timing of Payment Integrity solutions / value streams to be included in retail like offering.
• Assessment by value stream of impact to legacy Payment Integrity solutions in retail like ecosystem - how it should function, what would need to change, how to leverage AI, definition around go-forward use of the Payment Integrity solution.
• Value stream analysis including : COB, Claim Editing, Payment Policy, W&E, Fraud, Abuse, Provider Education, Claim Cost Management, Data Mining.
• Creation of overarching roadmap highlighting when and how existing Payment Integrity solutions will be deployed in retail / real-time settlement environment, by value stream.
• For each value stream, design of how IP behind each legacy Payment Integrity product will be applied in future retail state - how deployed, how accuracy will be fostered, how AI will be leveraged, and how savings will be tracked as Payment Integrity solutions are deployed in the provider Revenue Cycle Management workflow to avoid inaccurate claims.
• Development of use cases and scenarios by value stream to evaluate impact to medical cost savings by product (e.g., claim denied and not rebilled in provider workflow vs. existing environment and impact to affordability).
• Design how existing pre-pay and post-pay Payment Integrity solutions need to be adapted to complement retail environment and enabled by AI, including detection of new payment vulnerabilities that emerge because of new capabilities in the ecosystem.
• Creation of capital plan (as needed) to enhance / modify products where deployment of the Payment Integrity solutions and analytics will change.
• In partnership with actuarial teams, alignment on reporting of medical cost savings by value stream in retail environment, and what changes will be required (if any).
• Development of financial impact of transitioning or eliminating the need for Payment Integrity products in a retail environment - revenue impact, pricing impact by value stream.
• Evaluation of impact to operating model, and volumes, by value stream and corresponding impact to workforce, overhead, tech debt, etc.

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 :

Preferred Qualifications :

Competencies :

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). The salary for this role will range from $156,400 to $268,000 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.