Senior Claims Examiner

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. Our team is dedicated to improving health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best.

• Review, process, and identify medical claims based on standard operating procedures on CPS.
• 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.
• Review and apply member benefit plans and provider contracts, pricing, CMS rate letters, and SCA's to ensure proper benefits and contract language is applied to each claim.
• 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 (notes in system, letter to typing) on all overpayments created by the examiner or any overpayments identified by the examiner.
• Support implementation of updates to the current procedures and participate in new system updates and training.
• Communicate and collaborate with external stakeholders (e.g., members, family members, providers, vendors) to resolve claims errors/issues, using clear, 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
• 1+ years of experience processing medical, dental, prescription, or mental health claims
• 1+ years of experience working in a fast-paced, high-volume environment processing 50+ claims per day
• 2+ years of experience in a metric-based environment (production, quality)
• Proficiency with Microsoft Office Outlook
• Proficiency with Microsoft Office Word
• Proficiency with Microsoft Office Excel
• Ability to navigate and learn new and complex computer system applications
• Reside within commutable distance to the office
• Ability to work full-time, Monday-Friday

• Proven exceptional ability to organize, prioritize, and communicate effectively

At Optum, we believe everyone deserves the opportunity to live their healthiest life. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes.

UnitedHealth Group is 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.