Lead Claims Analyst
2 weeks ago
Optum is a worldwide leader in healthcare solutions, leveraging technology to enhance the well-being of millions. The contributions made by our professionals significantly impact health outcomes by linking individuals with essential care, pharmacy benefits, data, and resources necessary for optimal health. Our culture is rooted in diversity and inclusion, supported by skilled colleagues, comprehensive benefits, and opportunities for career advancement. Become a vital part of the communities we serve as we strive to promote health equity globally.
The Senior Claims Examiner plays a crucial role in delivering claims support by reviewing, analyzing, and investigating intricate healthcare claims to identify inconsistencies, validate pricing, confirm prior authorizations, and facilitate payment processing. Proficiency in navigating various computer systems to retrieve essential information is required. A keen attention to detail is paramount to ensure accuracy, which in turn guarantees the prompt processing of claims.
This position operates on a full-time basis, with a standard workweek from Monday to Friday. Flexibility is necessary to accommodate any of our 8-hour shift schedules during business hours. Occasionally, overtime or weekend work may be required based on operational needs.
Key Responsibilities:
- Assess, process, and categorize medical claims in accordance with established operating procedures.
- Implement relevant processes and protocols for claims processing, including adherence to policies, grievance procedures, state mandates, and guidelines.
- Evaluate and apply member benefit plans and provider agreements to ensure accurate application of benefits and contractual language.
- Meet weekly and monthly performance 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 adjust escalated claims to resolve complex payment issues.
- Analyze and adjudicate intricate claims initiated by providers using strong analytical and problem-solving skills.
- Generate documentation for any overpayments identified during the claims examination process.
- Assist in the implementation of updates to existing procedures and participate in training for new systems.
- Engage and collaborate with external stakeholders to resolve claims-related issues, ensuring clear communication for understanding.
- Ensure compliance with all claims reporting requirements and complete necessary production reports.
Your efforts will be recognized and rewarded in an environment that challenges you while providing clear guidance for success in your role, along with opportunities for professional growth.
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 over 50 claims daily for at least 1 year.
- Over 2 years of experience in a metric-driven environment focusing on production and quality.
- Proficient in Microsoft Office Suite, including Outlook, Word, and Excel.
- Adept at navigating and learning new complex computer applications.
- Ability to work full-time, with flexibility for shift schedules.
Soft Skills:
- Demonstrated ability to organize, prioritize, and communicate effectively.
At UnitedHealth Group, we are dedicated to improving health outcomes and ensuring the health system works better for everyone. We believe in equitable access to health for all individuals, regardless of their background. Our commitment extends to addressing health disparities and enhancing health outcomes as a core priority.
Diversity fosters a healthier workplace: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer, ensuring that all qualified applicants receive consideration for employment without discrimination.
UnitedHealth Group maintains a drug-free workplace, requiring candidates to pass a drug test prior to employment.
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