Lead Claims Analyst
2 weeks ago
Optum is a leading global entity dedicated to enhancing healthcare delivery through innovative technology, assisting millions in achieving better health outcomes. The role you will undertake is pivotal in connecting individuals with essential care, pharmacy benefits, and vital resources, fostering a healthier community. Here, you will be part of a culture that values diversity, inclusion, and professional growth, all while making a significant impact on health equity worldwide.
The Senior Claims Examiner plays a crucial role in providing comprehensive claims support by meticulously reviewing, analyzing, and investigating intricate healthcare claims. This position requires identifying discrepancies, validating pricing, confirming prior authorizations, and ensuring accurate processing for payment. Proficiency in navigating various computer systems to retrieve essential information is essential, as is a keen attention to detail to guarantee accuracy and timely claim processing.
This full-time position operates Monday through Friday, with the necessity for flexibility in working any of our 8-hour shift schedules during standard business hours. Occasionally, overtime or weekend work may be required based on business needs.
Key Responsibilities:
- Assess, process, and categorize medical claims in accordance with established operational procedures.
- Implement appropriate processes and guidelines for claims processing, including compliance with state mandates and CMS/Medicare standards.
- Evaluate member benefit plans and provider agreements to ensure correct application of benefits and contractual language.
- Achieve weekly and monthly targets, maintaining a quality standard of 95% and processing over 90 claims daily.
- Scrutinize each claim for correct coding of CPT and ICD codes against billed charges.
- Manually resolve escalated claims to address complex payment issues.
- Adjudicate intricate medical provider-initiated claims utilizing analytical and problem-solving skills.
- Generate documentation for any overpayments identified during the examination process.
- Assist in the implementation of updates to current procedures and participate in training for new systems.
- Engage with external stakeholders to resolve claims discrepancies, ensuring clear communication for understanding.
- Fulfill all claims reporting requirements, including daily production and weekly pending reports.
Your performance will be recognized and rewarded in an environment that challenges you while providing clear guidance for success in your role and opportunities for career advancement.
Qualifications:
- High School Diploma or GED.
- Minimum age of 18 years.
- At least 1 year of experience in processing medical, dental, prescription, or mental health claims.
- Experience in a fast-paced environment handling 50+ claims daily for over a year.
- Over 2 years of experience in a metric-driven environment focused on production and quality.
- Proficient in Microsoft Office applications including Outlook, Word, and Excel.
- Adept at navigating and mastering new and complex computer systems.
- Ability to work full-time with flexible scheduling during business hours.
Essential Skills:
- Demonstrated ability to organize, prioritize, and communicate effectively.
At UnitedHealth Group, we are committed to improving health outcomes and ensuring that everyone has the opportunity to lead a healthier life. We recognize the barriers to good health that disproportionately affect marginalized communities and are dedicated to delivering equitable care that addresses these disparities.
We embrace diversity as a cornerstone of a healthier workplace. UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer, ensuring all qualified applicants 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 maintains a drug-free workplace, and candidates must pass a drug test prior to employment.
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