Senior Claims Examiner

2 days ago

Pipe Creek, Texas, United States Optum Full time
Senior Claims Examiner Job Description

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives.

The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best.

Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities.

We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes.

Job Summary

The Senior Claims Examiner is responsible for providing claims support to our teams in reviewing, analyzing, and researching complex health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment.

You'll need to be comfortable navigating across various computer systems to locate critical information. Attention to detail is critical to ensure accuracy which will ensure timely processing of the member's claim.

Key Responsibilities
  1. Review, process and identify medical claims based on standard operating procedures on CPS.
  2. Apply appropriate processes and procedures to process claims (e.g., claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates).
  3. Review and apply member benefit plans and provider contracts, Pricing, CMS rate letter, SCA's etc. to ensure proper benefits and contract language is applied to each claim.
  4. Weekly/monthly goal of batches including meeting and maintaining a 95% quality standard and production standard of 90+ claims per day.
  5. Examine each claim for appropriate coding of CPT and ICD codes against charges that are billed and entered.
  6. Manually adjust pended escalated claims to resolve complex issues related to claim payments.
  7. Adjudicate complex medical provider-initiated claims using analytical/problem solving skills.
  8. Create and generate any overpayment documentation (notes in system, letter to typing) on all overpayments created by the examiner or any overpayments identified by examiner.
  9. Support implementation of updates to the current procedures and participate in new system updates and training.
  10. 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.
  11. Ensures all claims reporting requirements are met; complete daily production reports and weekly pending reports.
Requirements
  • High School Diploma / GED
  • Must be 18 years old 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 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 19500 W INTERSTATE, San Antonio TX 78257
  • Ability to work full time. Monday - Friday.
Soft Skills

Proven exceptional ability to organize, prioritize and communicate effectively

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