Experienced Claims Analyst

2 weeks ago

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

Optum is dedicated to transforming healthcare delivery for seniors through a physician-led approach. Our commitment is to ensure that our patients receive the necessary care from compassionate healthcare professionals. We collaborate with various Medicare Advantage health plans and are poised for ongoing expansion.

The Senior Claims Examiner plays a crucial role in providing comprehensive claims support. This position involves reviewing, analyzing, and investigating intricate healthcare claims to pinpoint discrepancies, validate pricing, confirm prior authorizations, and facilitate payment processing. Proficiency in navigating multiple computer systems is essential to access vital information. A keen attention to detail is imperative to guarantee accuracy, which in turn ensures the prompt processing of claims.

This role requires a standard 8-hour workday, with operational hours from 6:00 AM to 6:00 PM CST. The position is full-time, Monday through Friday, with the expectation of flexibility to accommodate various 8-hour shift schedules during business hours. Occasionally, overtime may be necessary based on business requirements.

Key Responsibilities:

  • Review and process medical claims in accordance with established operating procedures.
  • Implement appropriate processes and protocols for claims processing, including adherence to relevant policies, state mandates, and CMS/Medicare guidelines.
  • Evaluate member benefit plans and provider contracts to ensure accurate application of benefits and contractual language.
  • Meet weekly and monthly goals, maintaining a quality standard of 95% and processing a minimum of 90 claims daily.
  • Assess claims for correct coding of CPT and ICD codes against billed charges.
  • Resolve complex issues related to claim payments by manually adjusting escalated claims.
  • Utilize analytical skills to adjudicate complex claims initiated by medical providers.
  • Document overpayment cases and generate necessary correspondence.
  • Participate in the implementation of updates to procedures and contribute to training on new systems.
  • Engage with external stakeholders to address claims errors and issues, ensuring clear communication.
  • Fulfill all claims reporting requirements, including daily production and weekly pending reports.

Performance will be recognized and rewarded in an environment that challenges you while providing clear guidance for success in your role and opportunities for development in other areas of interest.

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, high-volume environment handling 50+ claims daily.
  • 2+ years of experience in a metric-driven environment focused on production and quality.
  • Proficiency in Microsoft Office Suite.
  • Adept at navigating and learning complex computer systems.
  • Must be of legal age to work.
  • Ability to work full-time with flexibility for occasional overtime.

Preferred Qualifications:

  • 2+ years of experience in a similar high-volume claims processing environment.

Soft Skills:

  • Exceptional organizational, prioritization, and communication skills.

At Optum, we are committed to enhancing the health of individuals and improving the healthcare system for everyone. We believe in equitable care and strive to eliminate barriers to good health, particularly for historically marginalized groups.

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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