Claims Quality Auditor

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:

• Performs routine, structured work and responds to standard requests using established procedures, systems, and factual analysis
• Reviews, queries, and validates claims, members, and provider data across relevant systems to ensure accuracy of decisions, payments, recoveries, and settlements
• Analyzes claims against applicable policies, regulations, contracts, and mandates to identify errors, defects, and potential risks
• Calculates financial impact of claim errors and documents findings with appropriate supporting evidence
• Delivers objective, fact based audit determinations in a professional, non confrontational manner
• Escalates identified issues, defects, and trends to appropriate stakeholders and supports resolution through calibrations, rebuttals, or appeals
• Manages audit inventory, reporting tools, and workflows to ensure coverage, timely completion, and compliance with audit and rebuttal timelines
• Consistently meets production, quality, and accuracy metrics
• 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:

• Graduate
• Received a rating of ME3 or higher in the most recent common review cycle
• 2+ years prior experience in performing Focused Claim Review (FCR) with sound knowledge of the Healthcare terminology
• 1+ years of experience within a matrix organization, healthcare, or insurance company
• Knowledge of Pre-Pay and Post service program related claims
• Knowledge of theories, practices and procedures related to claims / claims quality on FCR (Focused Claim Review)
  • Sound knowledge of healthcare terminology
  • Hands on experience working on the FCR (Focused Claim Review) platform
  • Understands Pre Pay and Post Service claims programs
  • Understands claim payment processes and denial reasons
  • Basic knowledge of medical documentation
  • Basic understanding of procedure, revenue (Rev), and diagnosis (Dx) codes
  • Able to identify incorrect, abusive, and fraudulent procedure codes

Soft Skills:

• Interpersonal Skills - ability to deal and work with people with different backgrounds
• Prior knowledge / experience with account-based products 
• Decision - Making Skills - capable of arriving at the appropriate decisions after weighing the pros and cons of all the options in consultation with department managers / SMEs
• Communication Skills - excellent verbal and written communication skills in addition be a good listener to give value to the opinion and suggestion of others
• Accountability - Takes ownership of tasks, performance standard and quality results. Maintains necessary attention to detail to achieve high level performance
• Problem Solving - Solution Driven Approach Skills - demonstrate ability to review problem, troubleshoot root cause issues and determine path to resolution with appropriate guidance
• Flexible - Able to work effectively in a changing environment and contribute innovative ideas
• Accuracy and Efficiency - Excellent time management and organizational skills balancing multiple priorities. Accurate when processing detailed tasks while meeting deadlines
• Self-starter, able to independently, drive work and prioritize work with moderate oversight

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.