Senior Claims Specialist
7 days ago
For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.
Responsible for processing, auditing, and adjusting all facility medical claims, appeals and prepayment audits. Answers incoming telephone inquiries, and accurately and thoroughly documents problems and resolutions. Troubleshoots claims that have been identified as needing additional work in the areas of eligibility, referral authorization and contracting or provider set-up. Trains and assists other analysts with problem claims and escalated telephone calls.
Primary Responsibilities:
- Consistently exhibits behavior and communication skills that demonstrate Optum's commitment to superior customer service, including quality, care and concern with each and every internal and external customer
- Processes all types of medical claims and adjusts medical disputed claims (Professional and Facility) according to department, contract, and regulatory requirements
- Performs prepayment audit on all types of medical claims (Professional and Facility) according to department, contract, and regulatory requirements
- Answers telephone inquiries through the "Automated Call Distributor (ACD) Telephone System" as needed
- Identifies individual provider needs and takes appropriate steps to satisfy those needs
- Updates authorization information based on information obtained from provider
- Troubleshoots problem claims to resolve provider issues or systematic issues
- Verifies and interprets information in all vendor contracts to resolve issues
- Trains analysts and monitors general office support functions as needed
- Analyzes work processes, identifies areas needing improvements and initiates necessary steps to make changes
- Participates in the continuous quality improvement of IMCS core business system
- Follows unit procedures for performing call processing, claim adjustments and denials and references Policies and Procedures, job aides, provider contracts, and other reference materials to assure complete and accurate decisions
- Uses, protects, and discloses Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
One year of post-high school education can be substituted/is equivalent to one year of experience.
Required Qualifications:
- Commercial and/or Medicare Facility claims processing experience and knowledge of AB1455 regulations
- 2+ plus years of healthcare claims processing experience in a managed care environment with at least 2+ years working with facility provider disputes
- Proven extensive knowledge of medical terminology, standard claims forms and facility billing coding, ability to read/interpret contracts, standard reference materials(PDR,CPT, Revenue, HIPPS, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge
- Proficiency with Microsoft Office to include Outlook, Excel, Word, etc.
- Ability to train onsite in our El Segundo, CA office for 4-6 weeks
- Experience in an indemnity and/or HMO setting processing, auditing, or adjusting facility claims
- Ability to process a variety of complex PDRs - Dialysis, Home Health, Skilled Nursing and Inpatient and Outpatient
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: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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