Claims Representative Senior - Remote in CA & NV

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.

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.

If you are located in California or Nevada, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• 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 or GED
• Must be 18 years of age or older
• Claims adjudication experience is required
• Knowledge of different lines of business. Commercial, Medi-Cal, Medicare, medical procedure code knowledge and knowledge professional versus facility claims processing.
• 3+ years related experience and/or training with intermediate to advanced knowledge claims processing, compliance and regulatory governing agencies (CMS, DMHC, DHS); provider dispute and resolution process (AB1455), provider appeals.
• Correct Coding Initiatives (CCI edits), contract language interpretation, health plan eligibility and health care benefits, or equivalent combination of education and experience.
• 4+ years medical claims knowledge is required.
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
• Knowledge of healthcare regulations and guidelines including CMS, DHCS, and DMHC as pertains to AB1455.
• Ability to work any shift between the hours of 8:00 AM - 5:00 PM PST from Monday - Friday

Telecommuting Requirements:

• Reside within 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.

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

California, Nevada, Residents Only: The hourly range for this role is $19.47 to $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.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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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