Senior Claims Examiner
2 months ago
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.
The Senior Claims Examiner is responsible for providing claims support to our teams in reviewing, analyzing, and researching complex health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. You'll need to be comfortable navigating across various computer systems to locate critical information. Attention to detail is critical to ensure accuracy which will ensure timely processing of the member's claim.
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 of 6:00 am – 6:00 pm CST. It may be necessary, given the business need, to work occasional overtime. Our office is located at 19500 W INTERSTATE, San Antonio TX 78257.
Primary Responsibilities:
Review, process and identify medical claims based on standard operating procedures on CPS.
Apply appropriate processes and procedures to process claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates).
Review and apply member benefit plans and provider contracts, Pricing, CMS rate letter, SCA’s etc. to ensure proper benefits and contract language is applied to each claim.
Weekly/monthly goal of batches including meeting and maintaining a 95% quality standard and production standard of 90+ claims per day.
Examine each claim for appropriate coding of CPT and ICD codes against charges that are billed and entered.
Manually adjust pended escalated claims to resolve complex issues related to claim payments.
Adjudicate complex medical provider-initiated claims using analytical/problem solving skills.
Create and generate any overpayment documentation (notes in system, letter to typing) on all overpayments created by the examiner or any overpayments identified by examiner.
Support implementation of updates to the current procedures and participate in new system updates and training.
Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claims errors/issues, using clear, simple language to ensure understanding.
Ensures all claims reporting requirements are met; complete daily production reports and weekly pending reports.
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
Must be 18 years old or older
1+ years of experience processing medical, dental, prescription or mental health claims
1+ years of experience working in a fast-paced, high volume environment processing 50+ claims per day
2+ years of experience in metric-based environment (production, quality)
Proficiency with Microsoft Office Outlook
Proficiency with Microsoft Office Word
Proficiency with Microsoft Office Excel
Ability to navigate and learn new and complex computer system applications
Reside within commutable distance to 19500 W INTERSTATE, San Antonio TX 78257
Ability to work full time. Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6am - 6pm CST. It may be necessary, given the business need, to work occasional overtime.
Soft Skills:
Proven exceptional ability to organize, prioritize and communicate effectively
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.
#RPO #RED
-
Senior Claims Examiner, E&S
3 weeks ago
Jersey City, New Jersey, United States Arch Capital Group Full timeJob Title: Senior Claims Examiner, E&SWe are seeking a highly skilled Senior Claims Examiner to join our E&S Casualty Team at Arch Insurance Group Inc. This role will involve actively handling and managing an excess casualty caseload, with a focus on identifying and assessing coverage issues, developing and implementing strategy, and resolving matters of...
-
Senior Claims Examiner, E&S
1 month ago
Jersey City, New Jersey, United States Arch Capital Group Full timeJob Title: Senior Claims Examiner, E&SWe are seeking a highly skilled Senior Claims Examiner to join our E&S Casualty Team at Arch Insurance Group Inc. This role involves actively handling and managing an Excess casualty caseload, requiring strong analytical and problem-solving skills.Key Responsibilities:Identify and assess coverage issues, draft coverage...
-
Claims Examiner
2 weeks ago
Garden City, Michigan, United States Synectics Inc Full timeJob Title: Claims ExaminerJob Summary:Synectics Inc is seeking a skilled Claims Examiner to join our team. As a Claims Examiner, you will be responsible for investigating, evaluating, and settling claims in a fair and prompt manner.Key Responsibilities:Investigate and evaluate claims to determine their validity and liability.Apply technical knowledge and...
-
Senior Claims Examiner, E&S
1 month ago
Jersey City, New Jersey, United States Arch Capital Group Full timeJob SummaryWe are seeking a highly skilled Senior Claims Examiner to join our E&S Casualty Team. As a key member of our Claims Division, you will be responsible for actively handling and managing an excess casualty caseload.Key ResponsibilitiesIdentify and assess coverage issues, draft coverage position letters, and retain coverage counsel when...
-
Senior Claims Examiner
1 week ago
Iowa City, Iowa, United States EMC Insurance Full timeJob SummaryEMC Insurance is seeking a highly skilled Senior Casualty Claims Adjuster to join our team. As a key member of our claims department, you will be responsible for resolving complex claims and providing exceptional customer service.Key ResponsibilitiesReview claim notices, lawsuits, contracts, and policies to verify coverage, deductibles, claim...
-
Senior Claims Examiner, E&S
2 weeks ago
Jersey City, New Jersey, United States Arch Capital Group Full timeArch Capital Group is seeking a Senior Claims Examiner to join the E&S Casualty Team. In this role, the responsibilities include actively handling and managing an Excess casualty caseload.Key Responsibilities Identify and assess coverage issues, draft coverage position letters, and retain coverage counsel, when necessary, as well as review coverage counsel's...
-
Claims Examiner
1 week ago
Garden City, New York, United States Generis Tek Inc Full timeJob Title: Claims Examiner - Insurance Claims SpecialistJob Summary:Generis Tek Inc is seeking a skilled Claims Examiner to join our team. As a Claims Examiner, you will be responsible for investigating, evaluating, and settling insurance claims. This is a remote position that requires strong analytical and communication skills.Responsibilities:Investigate...
-
Workers Compensation Claims Examiner
2 weeks ago
California City, California, United States Apidel Technologies Full timeJob SummaryApidel Technologies is seeking a skilled Workers Compensation Claims Examiner to join our team. As a key member of our claims team, you will be responsible for analyzing and processing complex workers' compensation claims, ensuring timely and cost-effective resolution.Key ResponsibilitiesAnalyze and process complex workers' compensation claims,...
-
Claims Examiner
1 month ago
California City, United States Apidel Technologies Full timeMinimum 3years of relevant CA WC claims experience is mandatoryCalifornia WC Claims handling experiencePrimary Purpose To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service...
-
Medical Claims Examiner
2 weeks ago
Clara City, Minnesota, United States Catholic Health Service Full timeKey Responsibilities:Conduct thorough reviews of departmental charges and medical documentation to ensure accuracy and compliance.Verify that all office visits, in-patient services, tests, and procedures are properly documented and correctly billed.Reconcile reports to ensure professional and clinical billing is accurate and up-to-date.Requirements:Strong...
-
Claims Examiner
2 weeks ago
Jefferson City, Missouri, United States Sedgwick Full timeAbout the Role:At Sedgwick, we're committed to taking care of people, and that starts with taking care of our colleagues. As a Liability Claims Representative, you'll be part of a global industry leader that's passionate about making a positive impact on the world. We're looking for driven individuals who embody our caring counts model and core values of...
-
Medical Claims Examiner
1 month ago
Oklahoma City, Oklahoma, United States Red Rock Behavioral Health Services Full timeJob SummaryWe are seeking a highly skilled Medical Claims Technician to join our team at Red Rock Behavioral Health Services. As a Medical Claims Technician, you will be responsible for researching insurance claim denials, determining the validity of the claim, and adjusting and resubmitting claims via multiple methods.Key ResponsibilitiesConduct thorough...
-
Medical Claims Examiner
3 weeks ago
Kansas City, Missouri, United States NTT DATA Group Corporation Full timeRemote Claims Processing AssociateNTT DATA's Client is seeking a skilled Remote Claims Processing Associate to join their team. As a key member of the team, you will be responsible for processing professional and hospital claim forms files by provider, reviewing policies and benefits, and ensuring compliance with company regulations regarding HIPAA,...
-
Senior Financial Analyst
2 weeks ago
Jersey City, New Jersey, United States Claims Solutions Full timeJob Title: Senior Financial AnalystAbout the Role:We are seeking a highly skilled Senior Financial Analyst to join our team at Claims Solutions. As a Senior Financial Analyst, you will play a critical role in supporting financial planning, analysis, and reporting within the business. You will utilize advanced accounting principles and financial modeling...
-
Insurance Claims Examiner
1 month ago
Kansas City, Missouri, United States Swope Health Services Full timeJob SummaryWe are seeking a highly organized and detail-oriented Insurance Clerk II to join our team at Swope Health Services. As an Insurance Clerk II, you will play a critical role in validating patient information and preparing and filing insurance claims in accordance with regulatory and contractual requirements.Key ResponsibilitiesValidate patient...
-
Senior Claims Specialist
2 weeks ago
Jersey City, New Jersey, United States Chubb Full timeJob Title: Senior Claims SpecialistChubb is seeking a highly skilled Senior Claims Specialist to join our team. As a key member of our claims department, you will be responsible for handling complex claims, providing exceptional customer service, and working closely with internal and external stakeholders.Key Responsibilities:Investigate and analyze claims...
-
Insurance Claims Examiner
1 month ago
Kansas City, Missouri, United States Swope Health Services Full timeJob Title: Insurance Clerk IAs an Insurance Clerk I at Swope Health Services, you will play a vital role in ensuring the accuracy and efficiency of our insurance claims process.We are seeking a highly organized and detail-oriented individual to join our team. If you have a passion for providing excellent support and are known for your organizational skills,...
-
Senior Claims Adjuster
1 week ago
Kansas City, Missouri, United States National General Insurance Full timeJob DescriptionNational General Insurance is seeking a skilled Senior Homeowner Field Adjuster to join our team. As a Senior Homeowner Field Adjuster, you will be responsible for investigating and confirming the facts of loss for complex Homeowner's Claims. You will determine coverage, damages, and adjust and negotiate claims within the limit of your...
-
Insurance Claims Examiner
1 month ago
Kansas City, Missouri, United States Swope Health Services Full timeAbout the RoleWe are seeking a highly organized and detail-oriented Insurance Clerk II to join our team at Swope Health Services. As an Insurance Clerk II, you will play a critical role in validating patients' information and preparing and filing insurance claims in accordance with insurance carrier's regulatory and contractual...
-
Senior Claims Specialist
1 week ago
Jefferson City, Missouri, United States Sedgwick Full timeAt Sedgwick, we're committed to delivering exceptional service and expertise to our clients. As a Senior Claims Specialist, you'll play a critical role in analyzing complex medical malpractice claims and providing resolution through well-developed action plans.Key Responsibilities:Analyze and process complex medical malpractice claims, investigating and...