The health care system is still evolving at a rapid pace. Technology is driving new advances in how patient care is delivered and how it's reimbursed. Now, UnitedHealth Group invites you to help us build a more accurate and precise approach to claims adjudication. In this role, you'll be responsible for the implementation and day to day performance of process activities related to claims research and resolution. This includes the review of claims, contracts, and fee schedules to identify processing, procedural, systemic and billing errors. Join us and build your career with an industry leader.
This position is responsible for reviewing all processed claims prior to payment release, and respond to Health Maintenance Organization (HMO) Enrollees for Commercial, Medicare, and Medicaid Enrollees. Responsible for daily auditing of managed care claim payments. Will be responsible to monitor claims compliance with Medicare by auditing reports. This person is the liaison with internal and external clients to resolve provider/member claim issues. Responsible to train claims examiners and is a resource relating to claims guidelines.Primary Responsibilities:
To perform daily audits of claims payments as established in the Claims Department Policies and Procedures.
To log all totals related to claims payment errors and examiner productivity for reporting purposes as established in the Claims Policies and Procedures.
Trains claim examiners regarding the system and claim procedures.
Audit pre check runs based on check run schedules.
Run and resolve various claims reports prior to check run.
Resolve claims based on CCI edit report to comply with CMS guidelines.
Serves as a resource to Management, Customer service, UM and other departments on claim issues.
To contribute to a fair and positive work environment by treating peers, superiors, subordinates, clients and vendor with professionalism and respect.
To perform other duties as directed.
We are looking for candidates with the following strong attributes:
Initiative – ability to thoughtfully and independently resolve problems
Organizational Skills – Ability to prioritize individual and departmental workload
Technical and computer expertise
Communication – Ability to identify and effectively communicate unresolved problems to Management in a timely manner
Teamwork/Workplace Civility – Ability to work well with others and contribute to the overall positive work environment of both the Department and the Company
- Demonstrates high reliability through consistent punctuality and attendance
- Minimum 2 years’ experience as a “Medical Claims Auditor” is required.
- Experience working with Medicare / Medicaid / Managed Care claims
- Knowledge of healthcare regulations and guidelines including:
- DHS guidelines
- Intermediate proficiency with Excel
- Associates Degree (AA) or 2-3 years related experience and/or training; or equivalent combination of education and experience
- Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding
UnitedHealth Group is a team of more than 260,000 people who are building career success through commitment, compassion and a desire to make a difference. Join us. Learn more about how you can start doing your life's best work.SM
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM
Diversity creates a healthier atmosphere: 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.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Claims examiner, Medicare audit, auditor, managed care, CMS, DMHC, DHS, Excel, La Palma, CA, California