Job Abstract

If you are locatedwithin the state of California,you will have the flexibility to telecommute* (work from home) as you take on some tough challenges.

Optumis 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 startCaring. Connecting. Growing together.

Let's talk about diplomacy. Let's talk about accuracy. Let's talk about howUnited Health Groupbecame a Fortune 6 leader in health care. We did it by working to become an undisputed leader in creating quality service and helping to improve the lives of millions. Now, here's where you come in. You can build on your problem solving skills by taking on responsibility for reviewing, researching, investigating and triaging claims that were denied to determine their correct status. You'll drive the action and communicate with appropriate parties regarding appeals and grievance issues. In turn, we'll provide you with the great training, support and opportunities you'd expect from a Fortune 6 leader.

The Claims QA Auditor performs quality assurance functions as they pertain to Claims pre/post payment transactions through identifying, documenting, and communicating information. The Claims QA Auditor maintains and provides statistical reports to Claims Management as requested. Works cooperatively with the Claims Trainer and Claims Team Leaders to propose and implement solutions to provide the best outcomes for our Groups, Members, and Providers. Supports activities related to internal/external audits to ensure timely dissemination of requested information/materials.

This position is full time. Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8am - 4:30pm PST. It may be necessary, given the business need, to work occasional overtime.

*All Telecommuters will be required to adhere to UnitedHealth Groups Telecommuter Policy.

Primary Responsibilities:

• Responsible for all aspects of quality assurance from a sample of random claims, check run reviews and Health Plan audits.
• Provide expertise and support by reviewing, researching, investigating, and auditing problematic claims.
• Analyze and identify trends and provide feedback and reports to reduce errors and improve claims processes and performance.
• Disseminate QA information/findings to claims staff in a timely manner in a clear and professional manner.
• Work with Claims Trainer to identify, document, and propose solutions for areas of variations from the norm, or potential high-risk areas requiring further one-on-one or group training.?
• Work with the Claims Regulatory Compliance Data Analyst to coordinate workflows related to the completion of Health Plan audits.
• Maintain worksheets that support the overall details of the QA program within the Claims Department.
• Provide the Director of Claims and Team Leaders with timely detailed monthly reports that outline departmental and individual statistical results as requested.
• Support the claims department by reviewing procedural documentation on claims processing as they relate to QA reviews. Provide recommendations based on findings.
• Perform other duties as directed to support claims functions, which are focused on achieving both departmental and organizational objectives.
• Direct and coordinate discrepancies to supporting internal departments by providing details of configuration issues that have caused system inadequacies.
• Coordinate with all departments (i.e.: Eligibility-Benefits, Managed Car Revenue and Network Management/Contracting and Finance and others) to ensure accurate information is in the system on a progressive basis.

This is a challenging role with serious impact. You'll need strong analytical skills and the ability to effectively interact with other departments to obtain original claims processing details.

You'll also need to effectively draft correspondence that explains the claim resolution/outcome as well as next steps/actions for the member.

Youll 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 old or older
• 2+ years of experience working in a Healthcare Managed Care environment.
• 2+ years of experience in reviewing Claims Adjudication data
• Knowledge of CPT, RBRVS, ICD-10 coding, ASA, PDR, and regulatory requirements set forth by the DMHC, CMS and DHS agencies.
• Proficiently skilled in the application and use of Windows Microsoft Word
• Microsoft Excel
• Microsoft Outlook.
• Ability to work 8am-4:30pm PST

Preferred Qualifications:

• Knowledge and experience of DRG, APC, & ASC claim pricing.
• Knowledge of health plan requirements for claims processing.
• Quality assurance program experience
• Must have knowledge of eligibility, benefits, copays, deductibles, and claims examining theory.
• Experienced in Health Plan and Vendor contract interpretation.
• Experience with HIPAA Regulation and California State Laws.

Telecommuting Requirements:

• Reside within the state of CA
• 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.

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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