Institutional Claims Examiner – Remote in PST

If you are located within Pacific Standard Time Zone, you will have the flexibility to telecommute* (work from home) as you take on some tough challenges.

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 Institutional Claims Examiner administers HMO contracts by processing medical claims in an efficient, cost-effective, and timely manner.  Responsible for determining financial responsibility between group, health plans and contracted hospitals for accurate processing of claims. The Institutional Claims Examiner is supervised directly by the Claims Supervisor, Manager, or Director and has regular interaction with patients, insurance providers, and other department and interdepartmental staff.

This position is full time (40 hours/week) Monday – Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6:00am – 2:30pm PST. It may be necessary, given the business need, to work occasional overtime or weekends.

We offer 2 weeks of paid training. The hours during training will be 8:00am to 5:00pm PST (but will need to be flexible), Monday – Friday. Training will be conducted virtually from your home.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

The following are exemplary essential job duties and responsibilities and are not intended to represent an all-inclusive listing of related essential functions of the position:

• Interprets contract coverage for medical claims and HMO patients.
• Verifies eligibility for HMO patients and co-pays prior to processing
• Receives calls from patients and providers; attempts resolution of all claims issues; and completes correspondence to patients or providers regarding claims adjudication including pending letters on unclean claims.
• Research authorizations and processes all claims received daily and maintains in date order to ensure compliance with federal and state regulations. 
• Adheres to guidelines for workflow and filing/processing patterns. Prepares claims for medical review correctly
• Maintains good working knowledge of system/internet and online tools. Must also utilize third party pricing software and any Medicare Prospective payment modules
• Advise Asst. Supervisor, Manager and/or Director of Claims of system and or contract processing issues.
• Ability to process claims institutional /hospital claims for all types for services related to the financial risk of the hospital/health plans.
• Applies correct vendor contract rates and review fee schedules to validate the processing of claims
• Ability to process claims manually from paper or in the system in an electronic format. 
• Apply all regulatory guidelines to the claims and process hospital related Provider Disputes.
• Must adjudicate services billed on both UB-04 and CMS-1500 claims forms 
• May be assigned special project or other assignments and work tasks that are generally within the scope and level of the position, and relative to the need for flexible Company operations.

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 Institutional claims adjudication experience in a Managed Care/IPA environment or Health plan setting
• Knowledge of medical terminology, ICD10 and CPT/RVS/HCPCS codes required including modifiers
• Ability to work any of our 8-hour shift schedules during our normal business hours of 6:00am – 2:30pm PST, Monday – Friday. It may be necessary, given the business need, to work occasional overtime or weekends

Preferred Qualifications: 

• Epic System experience

Telecommuting Requirements:

• Reside within Pacific Standard Time Zone
• 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

Soft Skills:

• Must have excellent verbal, written and interpersonal communication skills
• Must be proficiently skilled in the application and use of Windows, Word Perfect, Excel, Outlook and the Internet
• Strong working knowledge of Medicare Diagnosis-Related Group (DRG) pricing, OPPS APC pricing, Ambulatory Surgery pricing, ESRD pricing and RBRVS payment guidelines
• Understands eligibility, enrollment, referral and authorization issues
•  Knowledge of prompt payment guidelines for clean and unclean claims
• Process claims efficiently, maintains acceptable quality of at least 95% on reviewed claims, meets production standards consistently and daily, applies correct vendor contract rates to processing procedures of claims, prepares claims for medical review and signature review, applies correct compliance date on claims, knowledgeable of all time frames for processing all claims and maintains good working knowledge of system/internet and online tools used to process claims
• Clerical ability necessary, including ten-key calculator, computer, and light (35 wmp with accuracy) typing skills
• Ability to multi-task in an efficient, thorough, and prioritized manner; to work quickly, accurately and independently; and, to anticipate needs and solve problems
• Work with spirit of enthusiasm, teamwork, cooperation and a sense of urgency, and maintain a high degree of confidentiality over all matters in the course of business operations including patient and employee information
• Ability to successfully uphold the established customer service standards and Company Mission Statement

California, Nevada, OR Washington Residents Only: The hourly range for this is $19.47 – $38.08 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

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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