Claims Representative Senior – Remote in CA OR NV

If you are located within the state of California OR Nevada, 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. 

Responsible for performing research and analysis to facilitate the resolution of provider/member claims issues based on regulatory requirements.

This position is full-time, Monday – Friday. Employees are required to have flexibility to work any shift schedules during our normal business hours of 8:00 am – 5:00 pm PST. 

We offer weeks of paid on-the-job training. The hours of the training will be based on schedule or will be discussed on your first day of employment. 

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

Primary Responsabilities:  

• Performs complex and extensive research, analysis and logical conclusions of paper and electronic claims to resolve disputes by providers, members and health plans. Conducts necessary follow-up with internal departments within set timeframes to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration
• Acts as a department resource and gives support to Customer Service and research’s Practice Connect issues for resolution. Responds to provider calls related to provider disputes and appeals for incoming provider / member disputes
• Identify, trend, and report the Provider Dispute and Resolution process for Monarch Healthcare management and prepare reports for management summarizing observations and recommendations for quality improvement
• Provides qualified data to the Business Operations Compliance & Regulatory Manager for incorporation into training programs and policies and procedures. Confers with management to assess training needs in response to identified trends  
• Collaborates with other departments and management to implement and reinforce policy quality standards
• Regular and consistent attendance
• Other duties may be assigned

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
•  3+ years of related experience and / OR training with intermediate (to advanced) knowledge of claims processing, compliance and regulatory governing agencies (CMS, DMHC, DHS); provider dispute and resolution process (AB1455), provider appeals
• 4+ years of experience with medical claims knowledge 
• Correct Coding Initiatives (CCI edits), contract language interpretation, health plan eligibility and health care benefits, OR equivalent combination of education and experience 
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals  
• Ability to write routine reports and correspondence 
• Ability to speak effectively before groups of customers or employees of the organization 
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume  
• Ability to apply concepts of basic algebra and geometry
• Ability to apply commonsense understanding to carry out instructions furnished in written, oral, or diagram form 
• Ability to deal with problems involving several concrete variables in standardized situations
• Detail oriented
• Knowledge of healthcare regulations and guidelines including CMS and DMHC as pertains to AB1455
• Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding 
• Intermediate skill levels in Microsoft Word, Microsoft Excel, Microsoft Access, and Microsoft Outlook 
• Ability to navigate internet 
• Ability to operate general office equipment (i.e., fax, copier)
• Ability to comprehend, interpret, and apply provider contract language
• Ability to work any shift between the hours of 8:00 AM – 5:00 PM PST from Monday – Friday

Telecommuting Requirements: 

• Reside within the state of California OR Nevada
• 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

Physical and Work Environment: 

• While performing the duties of this job, the employee is occasionally required to walk and regularly required to sit and use hands to finger, handle OR feel
• While performing the duties of this job, the employee is occasionally required to lift or exert force up to 10 pounds
• The noise level in the work environment is usually moderate

California OR Nevada 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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