Associate Claim Representative

This position is National Remote. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. 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 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.

As an Associate Claims Representative, you'll be responsible for analyzing complex healthcare claims that require research to determine action steps and mathematical calculations necessary to produce an accurate payment. The claims position requires a high level of quality which is to be maintained while achieving a productivity goal. You'll put your skills and talents to work as you review, research, and process medical claims. It's complex, detailed work. It's a fast-paced challenge. It's a job that calls on you to be thoughtful, resourceful, team-driven and customer-focused. To put it mildly, there is never a dull moment.

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 8:00 am - 5:00 pm. It may be necessary, given the business need, to work occasional overtime.

We offer 12 weeks of on-the-job training. The hours of training will be aligned with your schedule.

Primary Responsibilities:

• Research, identify and obtain data/information needed to help process claims or resolve claims issues (e.g., verify pricing, prior authorizations, applicable benefits).
• Ensure that proper benefits are applied to every claim.
• Apply knowledge of customer service and applicable law requirements to process claims appropriately (e.g., Service Level Agreements, performance guarantees). Identify and apply knowledge of new plans/customers to process their claims appropriately.
• Identify and resolve claims processing errors/issues and trends, as needed (e.g., related to system configuration, network, eligibility, data accuracy, vendor-related, provider).
• Resolve or address new or unusual claims errors/issues as they arise, applying appropriate knowledge or prior experience.
• Prepare, distribute, monitor, and review various daily reports for management for compliance.
• 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.
• Collaborate with internal business partners to resolve claims errors/issues (e.g., Subject Matter Experts, Network Management, IT/systems staff, Compliance, vendor management teams, contract teams).
• Document and communicate status of claims/investigations to stakeholders as needed, adhering to reporting requirements (e.g., status letters/reports).
• Achieve applicable performance metrics (e.g., productivity, quality, TAT).

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.