Lead Claims Analyst
2 weeks ago
Optum is dedicated to transforming healthcare delivery for seniors, ensuring they receive the necessary care from compassionate professionals. Our innovative care model focuses on enhancing the health of our patients while collaborating with various Medicare Advantage health plans.
The Senior Claims Examiner plays a pivotal role in our operations by providing essential claims support. This includes reviewing, analyzing, and investigating intricate healthcare claims to identify inconsistencies, verify pricing, confirm prior authorizations, and facilitate payment processing. Proficiency in navigating diverse computer systems is essential to access critical information. Precision and attention to detail are paramount to guarantee accuracy, which directly influences the timely processing of claims.
This position requires a commitment to a standard 8-hour workday, with operational hours from 6:00 AM to 6:00 PM CST. It is a full-time role, Monday through Friday, with the expectation of flexibility to accommodate various 8-hour shift schedules. Occasionally, overtime may be necessary based on business requirements.
Key Responsibilities:
- Review and process medical claims in accordance with established procedures.
- Implement appropriate processes to manage claims, adhering to policies, grievance procedures, state mandates, and CMS/Medicare guidelines.
- Evaluate member benefit plans and provider contracts to ensure accurate application of benefits and contractual language.
- Achieve weekly and monthly production goals while maintaining a 95% quality standard and processing over 90 claims daily.
- Assess claims for correct coding of CPT and ICD codes against billed charges.
- Resolve complex claim payment issues by manually adjusting escalated claims.
- Utilize analytical skills to adjudicate intricate provider-initiated claims.
- Document any overpayment situations, including system notes and formal communications.
- Assist in updating current procedures and participate in training for new system implementations.
- Engage with external stakeholders to resolve claims-related issues, ensuring clear communication.
- Meet all claims reporting requirements, including daily production and weekly pending reports.
Performance in this role will be recognized and rewarded, providing a challenging environment with clear guidance for success and opportunities for professional development.
Required Qualifications:
- High School Diploma or GED.
- Minimum of 1 year of experience in processing medical, dental, prescription, or mental health claims.
- At least 1 year of experience in a fast-paced environment handling 50+ claims daily.
- 2+ years of experience in a metric-driven environment focused on production and quality.
- Proficiency in Microsoft Office Suite.
- Aptitude for navigating and mastering new computer systems.
- Must be at least 18 years old.
- Ability to work full-time, Monday through Friday, with flexibility for occasional overtime.
Preferred Qualifications:
- 2+ years of experience in a high-volume claims processing environment.
Soft Skills:
- Exceptional organizational, prioritization, and communication skills.
At Optum, we are committed to promoting health equity and addressing disparities in healthcare access and outcomes. We believe in creating a diverse and inclusive workplace where every individual is valued and respected.
Optum is an Equal Employment Opportunity / Affirmative Action employer. 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.
Optum maintains a drug-free workplace. Candidates must pass a drug test prior to employment.
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