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Senior Claims Examiner

2 months ago

San Antonio, Texas, United States Optum Full time
Job Title: Senior Claims Examiner

We are seeking a highly skilled Senior Claims Examiner to join our team at Optum. As a Senior Claims Examiner, you will play a critical role in reviewing, analyzing, and researching complex healthcare claims to ensure accuracy and timely processing.

Key Responsibilities:
  • Review and process medical claims based on standard operating procedures
  • Apply appropriate processes and procedures to process claims, including claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, and benefit plan documents/certificates
  • Examine each claim for appropriate coding of CPT and ICD codes against charges that are billed and entered
  • Manually adjust pended escalated claims to resolve complex issues related to claim payments
  • Adjudicate complex medical provider-initiated claims using analytical/problem-solving skills
  • Support implementation of updates to current procedures and participate in new system updates and training
  • Communicate and collaborate with external stakeholders to resolve claims errors/issues
Requirements:
  • High School Diploma/GED
  • Must be 18 years of age or older
  • 2+ years of experience in a metric-based environment (production, quality)
  • 1+ years of experience with working in a fast-paced, high-volume environment and processing 50+ claims per day
  • 1+ years of experience with processing medical, dental, prescription, or mental health claims
  • Proficiency with Microsoft Office Suite (Microsoft Word, Microsoft Excel, Microsoft Outlook, etc.)
  • Ability to navigate and learn new and complex computer system applications
Preferred Qualifications:
  • 2+ years of experience with working in a fast-paced, high-volume environment and processing 50+ claims per day
About Optum:

At Optum, we are committed to helping people live healthier lives and making the health system work better for everyone. We believe that everyone deserves the opportunity to live their healthiest life, regardless of their background or circumstances. Our mission is to provide high-quality, patient-centered care that addresses health disparities and improves health outcomes.

We are an equal employment opportunity/affirmative action employer, and 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.