Senior Claims Analyst

1 week ago

San Antonio, Texas, United States Optum Full time
Job Overview

Optum is a leading global organization dedicated to enhancing health outcomes through innovative technology and comprehensive care solutions. Our mission is to empower individuals to achieve optimal health by providing essential resources, pharmacy benefits, and data-driven insights. We foster a culture of diversity and inclusion, offering talented colleagues, extensive benefits, and opportunities for professional growth. Become a part of our commitment to advancing health equity on a global scale.

The Senior Claims Examiner plays a crucial role in delivering claims support by meticulously reviewing, analyzing, and investigating intricate healthcare claims. This position involves identifying discrepancies, verifying pricing, confirming prior authorizations, and facilitating the payment process. Proficiency in navigating various computer systems is essential to access vital information, while a keen attention to detail is necessary to ensure accuracy and timely processing of claims.

This role is structured as a full-time position, with operational hours from Monday to Friday. Flexibility to accommodate various 8-hour shift schedules during standard business hours is required. There may be instances where overtime or weekend work is necessary based on business needs.

Key Responsibilities:

  • Assess, process, and categorize medical claims in accordance with established operating procedures.
  • Implement appropriate protocols and guidelines for claims processing, including state mandates and CMS/Medicare regulations.
  • Evaluate member benefit plans and provider agreements to ensure accurate application of benefits and contractual language.
  • Achieve weekly and monthly batch goals while maintaining a quality standard of 95% and processing over 90 claims daily.
  • Scrutinize claims for correct coding of CPT and ICD codes against billed charges.
  • Manually resolve escalated claims to address complex payment issues.
  • Adjudicate intricate claims initiated by providers using analytical and problem-solving skills.
  • Generate documentation for any overpayments identified, including system notes and correspondence.
  • Assist in the implementation of procedural updates and participate in training for new systems.
  • Engage with external stakeholders to resolve claims-related errors or issues, ensuring clear communication.
  • Fulfill all claims reporting requirements, including daily production and weekly pending reports.

Your contributions will be recognized and rewarded in an environment that encourages personal and professional development, providing clear guidance on achieving success in your role.

Required Qualifications:

  • High School Diploma or GED equivalent.
  • 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.
  • 2+ years of experience in a metrics-driven environment focusing on production and quality.
  • Proficient in Microsoft Office Suite, including Outlook, Word, and Excel.
  • Adept at navigating and learning complex computer systems.
  • Ability to work full-time with flexible scheduling during standard business hours.

Soft Skills:

  • Exceptional organizational, prioritization, and communication skills.

At UnitedHealth Group, we are committed to creating a healthier world. We believe in equitable access to healthcare for all individuals, regardless of their background. Our focus on diversity and inclusion is integral to our mission, as we strive to address health disparities and improve outcomes for everyone.

UnitedHealth Group 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.

UnitedHealth Group maintains a drug-free workplace. Candidates must pass a drug test prior to employment.

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