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Senior Claims Analyst
2 months ago
Optum is a worldwide leader in healthcare services, leveraging technology to enhance the well-being of millions. The contributions you make will significantly influence 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 talented colleagues, comprehensive benefits, and opportunities for professional growth. Become a part of our mission to promote health equity globally.
The Senior Claims Examiner plays a pivotal role in providing claims support by meticulously 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 vital information is essential. A keen attention to detail is crucial to ensure accuracy, which in turn guarantees the prompt processing of claims.
This is a full-time position with a requirement for flexibility in working any of our 8-hour shifts during standard business hours. There may be occasions where overtime or weekend work is necessary based on business needs.
Key Responsibilities:
- Evaluate, process, and categorize medical claims in accordance with established operating procedures.
- Implement appropriate protocols and procedures for claims processing, including policies, grievance procedures, state mandates, and CMS/Medicare guidelines.
- Assess and apply member benefit plans and provider contracts to ensure accurate application of benefits and contractual language.
- Meet weekly/monthly batch goals while maintaining a quality standard of 95% and a production standard of processing 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 and collaborate with external stakeholders to resolve claims discrepancies, ensuring clear communication.
- Ensure compliance with all claims reporting requirements and complete necessary production 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 development in other areas of interest.
Required 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 processing 50+ claims daily for at least 1 year
- Over 2 years of experience in a metric-driven environment
- Proficient in Microsoft Office Suite, including Outlook, Word, and Excel
- Ability to learn and navigate complex computer systems
- Availability to work full-time with flexibility in scheduling
Soft Skills:
- Exceptional organizational, prioritization, and communication skills
At UnitedHealth Group, we are dedicated to improving health outcomes and ensuring the health system functions effectively for everyone. We believe in equitable access to health for all individuals, regardless of race, gender, sexuality, age, location, or income. We are committed to addressing health disparities and enhancing health outcomes, which is a priority reflected in our mission.
Diversity fosters a healthier environment: 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, and candidates must pass a drug test prior to employment.
