Claims Quality Audit Representative

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. 

Primary Responsibilities:

• Achievement of individual productivity and quality standards
• Contribute to working on Volumes when required and asked by the Management or Stakeholder
• Examining and identifying overpayments in claims, securing savings through recovery, and communicating effectively (in both written and spoken forms) to confirm and retrieve overpayments. Keeping recovery records updated with accurate information and documentation is also required
• Be able to learn and adapt to various claim system platforms and analyze claim payments for validation of potential other payor liability
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• 2+ years of experience using E&I & M&R claims platform
• 2+ years of health care experience working with claims data and / or medical codes 
• 2+ years of experience with medical claims auditing and researching medical claims information
• 2+ years of experience working with processing and reviewing medical claims platforms
• Experience analyzing large data sets to determine trends or patterns
• Experience reading and interpreting clinical coding guidelines, provider contracts, fee schedules, and claim payment policies
• Experience within the UHC healthcare environment and systems
• Knowledge and understanding of medical claims terminology, CPT-4, J-codes, and ICD Diagnosis procedure codes
• Computer proficiency in Microsoft Office including Word (create documents), Excel (data entry) and Outlook (send email / calendar utilization) 
• Proven ability to work under high production and quality standards

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.

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