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. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
The
Claims Quality Audit Representative reviews and audits processed claims for accuracy and appropriateness in regard to coding, benefit payment and contract interpretation. This position will also assist in the development of various tools that improve business processes. In addition, the Claims Auditor will provide guidance to Claims Auditors and facilitate team projects.
This position is full time. Employees are required to have flexibilityv
We offer 90 days of on-the-job training. The hours of the training will be based on schedule or will be discussed on your first day of employment.
If you are located in San Antonio, TX, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities
- Reviews claims for payment accuracy to include financial, procedural and monetary appropriateness.
- Reviews contracts to ensure accurate payment has been made. Ensures contracts are accurately loaded into the system.
- Reviews issues, such as claims re-works, claims appeals, and payment discrepancies identified by customers and providers, responding in a timely manner.
- Assists in the development of systems that automate the identification of claims audit errors and tracks claims errors and resolutions.
- Assists in the development of tools to facilitate the sharing of information and feedback with customers.
- Participates in projects associated with compliance audits, focus audits, stop-losses and cost containment.
- Analyzes information flows, develops flow charts and decision trees and reports results.
- Analyzes data and reports results during audit initiatives.
- Understands, interprets and applies business policies and procedures that impact claims auditing and payment accuracy.
- Researches UB and HCFA guidelines in support of audit initiatives.
- Maintains current knowledge of CMS/Medicare Advantage regulations.
- Performs all other related duties as assigned.
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications
- High School Diploma / GED
- Must be 18 years of age or older
- 2+ years of health care claims examination experience
- Medical terminology, 10-key and computer literacy
- Proficient with Medicare processing guidelines, working knowledge of medical contracts, including Medicare reimbursement and negotiated rate methodologies
- Ability to organize, prioritize and communicate effectively
- Must have commonly-used knowledge of claims examination concepts, practices and rules, ICD and CPT/HCPCS coding and network contracts.
- Experience and judgment to plan, accomplish goals and effectively solve problems
- Ability to make decisions based on sound knowledge
- Performs a variety of tasks that may require a limited degree of creativity and latitude
- Ability to work any of our 8-hour shift schedules during our normal business hours of 6:00am - 6:00pm CST. It may be necessary, given the business need, to work occasional overtime.
Preferred Qualifications
- Knowledge of enterprise-wide claims management software
Telecommuting Requirements
- Reside within San Antonio, TX
- Ability to keep all company sensitive documents secure (if applicable)
- Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
- Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.
- All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.
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.
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