Healthcare Claims Quality

1 month ago

Redlands, United States Optum Full time

**If you are in Redlands, CA, you will have the flexibility to work from home and the office in this hybrid role* as you take on some tough challenges.**

**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.**

This position is 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 6:00am - 2:30pm. It may be necessary, given the business need, to work occasional overtime.

**Our office is located at 1615 Orange Tree Ln Redlands, CA. Employees will be required to work some days onsite and **some **days from home.**

We offer 8 - 12 weeks of paid training. The hours during training will be 6:00am to 2:30pm, Monday - Friday. **Training will be conducted onsite.**
- _All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy._

**Primary Responsibilities**:
The following are exemplary essential job duties and responsibilities and are not intended to represent an all-inclusive listing of related essential functions of the position:

- Responsible for all aspects of quality assurance from a sample of random claims, check run reviews and Health Plan audits.
- Provide expertise and support by reviewing, researching, investigating, and auditing problematic claims.
- Analyze and identify trends and provide feedback and reports to reduce errors and improve claims processes and performance.
- Disseminate QA information/findings to claims staff in a timely manner in a clear and professional manner.
- Work with Claims Trainer to identify, document, and propose solutions for areas of variations from the norm, or potential high-risk areas requiring further one-on-one or group training.
- Work with the Claims Regulatory Compliance Data Analyst to coordinate workflows related to the completion of Health Plan audits.
- Maintain worksheets that support the overall details of the QA program within the Claims Department.
- Provide the Director of Claims and Team Leaders with timely detailed monthly reports that outline departmental and individual statistical results as requested.
- Support the claims department by reviewing procedural documentation on claims processing as they relate to QA reviews. Provide recommendations based on findings.
- Perform other duties as directed to support claims functions, which are focused on achieving both departmental and organizational objectives.
- Direct and coordinate discrepancies to supporting internal departments by providing details of configuration issues that have caused system inadequacies.
- Coordinate with all departments (i.e.: Eligibility-Benefits, Managed Car Revenue and Network Management/Contracting and Finance and others) to ensure accurate information is in the system on a progressive basis.

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
- 2+ years of experience working in a Healthcare Managed Care environment.
- 2+ years of experience in reviewing Claims Adjudication data
- Must be 18 years of age OR older
- Ability to work full-time, Monday - Friday between 6:00am - 2:30pm including the flexibility to work occasional overtime given the business need

**Preferred Qualifications**:

- Knowledge of CPT, RBRVS, ICD-10 coding, ASA, PDR, and regulatory requirements set forth by the DMHC, CMS and DHS agencies.
- Knowledge and experience of DRG, APC, & ASC claim pricing.
- Knowledge of health plan requirements for claims processing.
- Quality assurance program experience is highly desirable.
- Knowledge of eligibility, benefits, copays, deductibles, and claims examining theory.
- Experienced in Health Plan and Vendor contract interpretation.
- Experience with HIPAA Regulation and California State Laws.

**Telecommuting Requirements**:

- Reside within commutable distance to 1615 Orange Tree Ln, Redlands, CA
- 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 Ski

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