Senior Claims Examiner
4 weeks ago
We are seeking a highly skilled Senior Claims Examiner to join our team at Optum. As a Senior Claims Examiner, you will be responsible for reviewing, analyzing, and researching complex healthcare claims to identify discrepancies, verify pricing, and process them for payment.
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
- Create and generate any overpayment documentation on all overpayments created by the examiner or any overpayments identified by the examiner
- 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, using clear and simple language to ensure understanding
- Ensure all claims reporting requirements are met, complete daily production reports, and weekly pending reports
- 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
- Reside within a commutable distance of our office
At Optum, we are committed to helping people live healthier lives and making the health system work better for everyone. We believe everyone deserves the opportunity to live their healthiest life, regardless of their background or circumstances. We are an equal employment opportunity/affirmative action employer and welcome applications from diverse candidates.
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