Requisition number: 2395133

Job category: Claims

This position is National Remote. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The C&S DSNP Maximum Out-of-Pocket (MOOP) Processor plays a critical role in protecting the member experience by proactively identifying, investigating, and resolving issues impacting Dual Eligible Special Needs Plan (DSNP) members' Maximum Out-of-Pocket accumulators.

This position is responsible for researching and resolving MOOP overages, performing detailed root cause analysis, and identifying trends across claims, accumulators, eligibility, vendor, and system processes. The role serves as a key partner in driving process improvements, reducing regulatory and financial risk, and ensuring DSNP members receive accurate benefits and cost-share protections.

Success in this role requires strong analytical skills, claims adjustment expertise, innovative problem-solving, and the ability to collaborate across internal and external business partners to implement sustainable solutions.

This position is full time (40 hours / week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime.

This will be on the-job-training and the hours of training will be during normal business

Primary Responsibilities:

• Review and work DSNP MOOP overages and accumulator discrepancies.

• Research claim history, benefit configuration, accumulator activity, and eligibility records to determine the cause of member impact.

• Perform claims adjustments and corrections within CSP Facets to resolve identified issues.

• Ensure timely and accurate resolution to minimize member and provider disruption.

• Maintain detailed documentation of findings, resolutions, and corrective actions.

• Conduct detailed root cause analysis for each overage or accumulator issue.

• Identify common defects, patterns, and process breakdowns across multiple cases.

• Group issues into meaningful categories to improve efficiency and drive scalable solutions.

• Develop recommendations for operational process improvements and system enhancements.

• Monitor recurring issues and assist in measuring corrective action effectiveness.

• Partner with Operations, IT, Compliance, Claims, Enrollment, Pharmacy, and vendor teams to address identified issues.

• Participate in remediation efforts designed to improve accumulator accuracy and compliance.

• Support development of sustainable controls that prevent future member impact.

• Assist with testing and validation of system fixes and process changes.

• Contribute to ongoing efforts to strengthen DSNP claim processing and member cost-share accuracy.

• Work closely with internal and external business partners to investigate complex member issues.

• Communicate findings, risks, and recommendations clearly to leadership and stakeholders.

• Escalate systemic concerns and regulatory risks when appropriate.

• Serve as a subject matter expert for DSNP MOOP-related inquiries and investigations.

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:

• High School Diploma / GED OR equivalent work experience

• Must be 18 years of age OR older

• 1+ years claims adjustment experience within CSP Facets.

• Experience researching and resolving complex claims and accumulator issues.

• Ability to perform root cause analysis and identify trends.

• Experience working in healthcare operations, claims processing, OR government healthcare programs.

• Ability to manage multiple priorities in a fast-paced environment.

• Ability to work independently with minimal supervision.

• Ability to work full time (40 hours / week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours 8:00am - 5:00pm. It may be necessary, given the business need, to work occasional overtime.

Preferred Qualifications:

• Experience supporting DSNP, Medicare, Medicaid, OR other government healthcare products.

• Knowledge of accumulators, member cost-share, and Maximum Out-of-Pocket (MOOP) processes.

• Experience partnering with IT teams on defect remediation and system enhancements.

• Understanding of healthcare regulatory requirements affecting member benefits and cost-share protections.

• Experience using data and reporting tools to identify trends and drive operational improvements.

• Experience with Microsoft Excel (sort, filter, formulas)

• Knowledge of SQL

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)

• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.

• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

Soft Skills:

• Strong written and verbal communication skills.

• Strong analytical and critical thinking skills.

*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 $24 - $43 per hour 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.